A Comparative Study Of Suxamethonium Induced Muscle Fasciculations

“A COMPARATIVE STUDY OF SUXAMETHONIUM INDUCED
MUSCLE FASCICULATIONS, POSTOPERATIVE MYALGIA
AND HYPERKALEMIA WITH THE PRECURARIZATION
AND SELF TAMING OF SUXAMETHONIUM.”

THESIS

FOR

DOCTOB OF MEDICINE

( ANAESTHESIOLOGY )

1991 DAYA SHANKAR

Thi» %& ernttlif Wm

ii« l!ulfii4.4iS micvsffArif pfurioS at stay

in tliis 4ki|»sslSMiiit «s rsquitad lay rsfuistiaias af

BoiMlailliiisiiii HaltVSdrSAty #

( v«c» mMom )

VxqM sssot Si^ MasA#
OapsjTtsMiat af Aasiastliaidi
HmhmUm MaAJUlSl Cai]*l
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ay £»s« £>sya i^atalcsr# liss bs«a csrrisA oat lay tlis e«iA
hiffisaif la Mm . iaspartment af Aasastasslology# I

Cailofs* JIasnsi (li.P*)*- ..

THi* ivilUU ea

itti# aiiJMiiJji •lo® 'WfMiai.a f©** M#©##
«»lv©3r*ity.

HAH QVm Dmgm. mnAmx: mf pmtmnml

•uptrvi«io& m& gnij&micm* Thm t«ehniqu«ii «sua

iitscrilasdi# w«ir« ii»di«rt»lMiii €e«iiSidiit« wd th«

olM%tw9kti&m hm^m Immn si»tlodlQ9Xlf eli«eluid fcid

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( A.K* O^WARA }

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^li!p ’’•iWPPWHilF WP PWr 4Pw ^fpwpiP'ipppip IBPWFPPPP PPWPw ..'41

lt*l»#lt« MadlcajL

ACKHOWUS DOlMgllT S

At tint 1 Kills t •xptKSK my d«sp««t

rsgsrds to sli th* iMitisuts# vlho hsvo b««ii tho subjvct
during th« mwc»m of w study*

2 t is %tlth profound k« 08« of grfttitudo that X pay
my ohmiBtmam to my aataemd taachar Or* Yarraif

ij,Am, Lacturar# iitpartmaot of iuuiaathaaioXogy* M •L.B •radical :
voiiaga# iShanaif for. abia guManca* invaXuabXa advioaa and
aehoXarXy icuitructioiui id)ich lad tha way of my oondwsttnf
tha praaant study suoeaasfuXly*

l jPRUSt pay my rsYsrsaea to !!•€;« siiaraMi# M«0*,

Ftofassor !> Hasd« fsapartaiaiit of Anaaa^siology* i

i

M*L*S» .MadioaX CoiXaga.* wh& laaiiaaolaiitXy assayad !

to dairaiop is na a guast fcur Joaoitladga of tt» wibjact* |

Xt is iiKpossibia for m to axprsss my isdaMaass ;

to ny rsYsrsd tssohar Pr« 4*Ji» iiMriiara« &«A*# Jitaadsr* |

iNKpartsM&t of iiaaasthssioloiyt Madioai Qoliafan *lliaiisi*|

. , ■■■ f'

Withoi^ Itis ffioastsiaotiva fmldanoa# Iwao istarast and |

syiiiaildiatio sttituds# it would sot bs possibls Ibr ms to
idsoiipliab this iMMelii*

, ,^1^011 iMSVlly iodibtad sad grstofui Jbr* ll•F*Siag|ll«
Soiiior «ad lfoid« Sopartaioiit of lloadissilJitry*

Medical Uolltgof JtiaESi# for him aiblo fiiforriaion
and •ttoouraging attitiaSo througiioiut l±i« ootarsa of tiio
protont oorlt*

l oc)maif2,«dg« doopost ••oaa of gratitude to
Pr« i»iidii« JUicturer# Depertmtot of

Anaesthesiology* M«Xi«3« Mediosl College# Chensi# whose
sincere and incr^^nse help mide the things easier to sw»

I acknowledge py debt to br*(Mrs*) V« Gupta# M»u«,
Jbecturer# Peparteent of 'Anaesthesiology#

Medical Collage# Ghansi# «Sio as a perpetual aouree of
'inspiration and knowledge beatowed uqpon m with refearkabla
generosity*

1 owe special thanks to Or* B*L* yenea# £li*0*#
Seader in Medical Statistics# Oapartment of social and
f*reir«atiire Medicine# M*l#*l* Medical Collega# dhattsi# for
his constant hslp at^ sui^port which helped mi in Mtalysing
the obsenration in appropriate naniwir* /

X liawe mi words 1» espress ny feeling towards w^f
parsnts who haiNi nmained continuotsi source of inspiretion
and encouragenient during my busy schedule# in conducti^ng
the study*

X SSI hii^Xy obXiged to slX ay oollsagies in tlui
ikijportwint of snsesliiesiologyt tf*!#*!* Medical ColXefS*

Jliafislir alw€yd aKtendad kind co-opsration to m during
thf! cowpi^tloia of this dsssertstion*

i. c«ii lasvsx forgst to thank Thomas

for his untiring «t£oxts, idkllm ^nj^s^sing this manuscxipt
in nics and mat form.

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$ux«iNttli<»ii.iiPi# m aidbiol.inii •»ttr of •ooeloio
mid, is tlMi iliort actiog dopolarisiog wm&lti tmlmmt

oi •oxmo'l^oiii'im produem mxcmXXmatt mmi»»trmimtd iotoiiatioo

ooBditiosis within ]JE}«>30 soe. tm sssociatod masolo

rolnxotion p«ir»i«t« «^to S mm, mm mmkXag it mXmm%

of ehoico dmim nmnorons ai«gno»tie Md aorgieiil j»too«diir«s

of ^ort Oiuratioa ouch oo mtdmmpmB, fexonehoooopr#

orl^OI»««Klle fioniimlotiodeis* onol diiototion oncl nodifiod

•lootto-Heofmaloivo thori^Y*

hole in ttui form of intojmittont wsoo oYon during ifiojor

iMiOniot oror tho md Jnaotioniki rocoftoro*

.i*;t tv -.i.-: , : -:■■ ■ '.t . •, J

hoopiiiioo 0i jiwMtionol roooptoro fcodwoo mdk hot
jgoroiotont dofoiori««tio» of tiotor^ooS nolcini ft

IHTBODaCTlQil

2

imxmBpGnmiwm to tlm «e«t]fJLein9liiMt« Thm d«p#jLaijrisiiti«Mi
t?p« of mum-~mM€smlMx: block in 4 mmiltiiig

into iiiit»«ii3>*ir fttl.aiistJ.eii*

Zncpit* of oojofi&g ropotatioii «i fdoal museZo
roloxafit dxug ho* oortolni odiror«« of foot iuiiCMiifttofi totli
it* mm* Xt* Agcmistie aetloo mar X««<S to too torr«ioi>fa>iit
of Br«<3ye«rdil« and bronctiospaawn# Iwsidaa toaMi jprodiMtioii
of nawjro-wwicular blswk itaalf la pracadad Tof faaciculaitlOB ;
CNT muscle tailchas aloogwitli incraasa in intjra^gaatiric and
intra-ocular praaaura* diubsisauaatlsf tiirparlialaMiaf altooagili;
mild and tranaiant in Iwalthiar patient a# oeaur* duriav
induction period, and maf to fatal in certain eaaaa* Thm

. ■ . ■ ii

aboea mentioned problama are to to faced imnmdiataljr after ;
toe auxamatoonium administration but poat-ope^atia-a period

■ ■ ■■ ... i

ia also ifi$>ortant ainea unpleasant w/folgima. m4 n^oglobinuriit
msi' occur aaan some da]fa after aurganr*

in addition to tliaaa potential problaimf
aujcamt tooniien induead prolon^ad ai^noaa and maligiiaBt
tipparpyraxia waj craata a grata situation in suaeaptibla
patiaiita* ftia administration of largar doaaa such as
during multiple intermittent doses or Z.v. infusion maf'
lead to the detelopment of iHhaae II block*

file aiuaele faeoiou tot ions altaost alvi^ precede
toe ' detodcpmaat «Mt neuro-muacular block and perhep* art
toa rasult of xecaptor atiiiiialatloii bf toe

V i ‘h*t. ; '-t goiy-'h. , .

a

•uxiifi«tlK>iiiiam« thmf &xm uaualXjf •••n ma tLm txvmoxB
mmx f«c«# finger m4 toes but eo«rs« m€ 'rignrotui

Ai#¥ oeeiut vJLtil jit gyi

^Hp^IPpI wipipi W *w«5f TW* I^PP T^ppffl!P0W”B(|pP“Pp^' ^PJPPPI^P ‘^NpMiMPBM PP^^pPPBP ^PlW^PPIr^WWp

ino<iP«iMiiit« e»f trunk and Xiiidni*

£»«ir«rity of viaibla faiMsicuXation in aXtari^ bf*
induction taebnigiae# inoda of imjcaiiiathoniiinr adininiatratioo
ac^ varloua prauonting meaauraa including pxueurariaation
and aalf taining*

poat-oporativa suxa-paina ara raallir troubiaaoiMi
and occur in naJoritF of patianta. Timy mwy ba <spinaraiiaad
or loeaiiaad aitli tha varying int«iaity fjsoii! atiM mhm» to
aavara incapacitating vuaeia pain and atiffnaaa* Tba onaat
la iiauaiiy within 24 to 48 hour a and uaualiy paraiat uptia
thraa and raraly iipto S*§ daya* '

Xncidanca and aavarity of ayaigiaa ara mich higliHir
in adult and adddla agad patiant. raioalaa# aseeapt duriog
pragnaacy ara laoca auacaptibla ahila children# eldter
patients and muacularly fit peraoiui have been found to be
leas prone* seeidea patiaat factors anaeathetio taohnlguair
position c€ patient# nature «id duration of aurgaij also
alter the AmmX&pmnt of such pains*

Xtiology of such pains is still wikncwn but wmmim
diWMiga dus' to suswmi ttionius is ihs aost |uroM»le esusa*
Winiiarous mmmm vara, end ara baiag sdoptad for pravantlim
of Hiasa pains bsesiisa'it mmm inoongrous to indsca pain

4

by th« liiseipXiKHi of tiology lAiich i« ootabliiiMid

to oooquor tb* poin* Hozmomt, tbM disoomfort of
iMiliiooit»K p«ln* my omo •aceooil 1b at of mtml ofoiratj.t'o
pbMOiiar* moA occaoionalXy mb* tlw patient loiloriiAiii
and delay tbalt atay pariod in tba lioapital*

Saif taninq and pracurariaatlon are among tba Moat
naafui pravaatiaa maauraa agadnat tba ocoiunranea of tlia
advaraa af facta of tba mt^watboniwm*

Saif taming of auaa«>faacieuiatloiia liaa baan
intxodnead in 1977 niiaii Saraba aueeaaafully attanuatad
ttMun witti tba halp of aaiall pra-txaataant doM of anna*
mthoniian itaalf* siibaaqoently* aimliar attanuation of
auxa-faacicMilationa baa baan raportad by Varma (1979)#
Wilaon* cunda# UitO) and Qlllml at al (1989} • Hotfavar#
aalf taming doaa itaalf mar induea mild faaolomlatioBa in
aoma oaaaa* MypaalMilafRie raap<mia to mmMmthonlvm baa
alao baan abown la» ba inbibitad aftar tba aalf taming
(iTiatta at al# 1980 1 Magaa# Gallagbar# 1984) • iloi#avai’«
wilaon# pnndaa (1989) hmwm failad to anppraaa tba ineidtmaa
of auxa-paina nitb tba Iwlp of tbia pxa*traalm)aift •

Piraomrairiaation ia parbapa tba moat widaly naad
pcaaantiva aNiaaura in tdiicb mall pira^traataant doaa of a
non^dopolaxisiai mnaela wAlmxmk ia §lwm 8*3 ida* prior
im tba' ii^iiiiniatration of anxamatbonitun# daUamint (49 mg#!
Ifoa tba first drug to ba vaad for aoeb pra-traatnant
(C« Paoidaont . 1914) « SnlMiaquantly# annllar doaoa of

OiiXlamiii* tmm S mf (lihittt, 19112} to SH) fig CB^nmitts*

Xtialil* 1981 ) hmvm lernmn xmcoimmMmd far tola purpaoi*

Morria iHum il9$7)« Ha^frliofar (lfS9> l»ini
«ia<sc«aafuli 3 r wkmI tul»CN8uriyriiM m» praetirarisatlon drug
•ine* than almost avory «r«ilabl« iton-<3«|M»lails«r lift* twan
•iraltt«t«d far this •ffleser Ifffi Millar# May#

1971i Cullaii# D*J«# 1971f Brodaky at «1# 1979| Baanatt*#
Khalil# 1981 r Tarraa at «1« 1983# M«a«y at al# 1910 and
&ullivm0 19 8S) •

^among tha OallmiM# d-tuboeurariiMB and l^aiiciitoniiM
tha Oallamiaa haa baan daaaribad aa baat affaetira loy callaa
( 1971 ) but Caaay at al ( 1981 ) haaa fbuhd tha JPaneutohiuM
to ba a battar chaioa and xrkalt at al (19IP) havra e 0 iialdarad
Hia d^tubeeiirarifia to ba mE»at affaetiaa* Contradiotary to
toa aforaaaid ri^orta# Farraa at al ( 1983 ) haTa aalaatad tha
Vaeuronitta to ba dn^ of ohoica* sintilarly# many othar
imraatigatora haaa raportad variabla but dafinita affieacy
of aarioua BaNh*>dapolarisara againat toa advaraa affaota of
auJttoatooiiiiam* Mowaaar# aaaaeiMbad antafoiiiwi* of a«tra<*
paralyaia loading to poor intubatiog eoaditioo haa ramain
a potantial problam ahan tha twthod of praourariaation ia
amployad*

G

Ttiw dri^ wm first prspsrsd icy Hsid Hunt «iil .

T«ir««u in iiOi« . But they fniJbid to rncognisn its musel*
parniysiiH' pmpnrty bncstisn tn«y W9xm ming th« druf on ttm
prnviounly eurarisni sniiwl* This ^slimbis propsrty of
drug tsiMsiMi obsotyursd for about 40 yrs lAsn Bcnrst ot si
Cif49) in Xtsiy and BMXiips (1940) in u*s«h« isseribsd
ttMK ^nsitro-Msteuiar blcKskinf action of tho drug* Castillo
4 19 SO) and l» da Boar (IfS^) also obsaraad iNManlar fNiral|Vis
of rapid ossat and shcart duration* fioon tha drug wm
i^eaptad ior clinical anaaathaaia and was populariaad bf
yon bardal o« and itliaslaff* S* (19S1I in dtoablioliii# inclc
at al (Itiil and Mayrhoifar* tiassfurtbar (19 ID in jutstria#
Bouma at al (19 $3) in draat Britain and JPOldar (19 S3) in

j §,.| I, y f Ijl H

aaag»oiind and a diabolina asrtar of atMMinic acid# «bi#i
consista of t«io asHStyladnolina welaattlan* Joinad fenab to baab*

' ',1% is a aliita arystallina substanca i #

mlatitniyif 'unstdtia and datariflntata rnpldlf In warn

nlMNisdMiiMi a ff d JNSs' salt ad iiutaiiatlMMiiin

i'

7

l!i relatl'^«ly atabl« tout to Is® atorod at 4®C m hyd«>ly»i«
occtar at xoon tan^ratura*

Ttia iatjraaaBoiia bolua of mixanattioaiwi (1-SI wp/lci>
i» tha moat prafarad routa with tha aaaraga iiatolwtioii
doaa of 25 - 190 mg* 9naat of paraljraia ocoiara withlii
10 - 30 aacanda Omratiofi of aetioa wariaa fsom 1 -to 5 mta*

Drug ia not affactiwa orally but cm ba giaao
iotra-muaoularly but with raduead affieaoir» i/V infusion
can also ba mmS to obtain auatainad action with tha rata
of IS mg/bi/mt*

Ttm axtramaly l»riaf duration of action ia toacauaa
of wary rapid hydroaia of atuemathtaiiuiR by m plaami

eholinaataraaa idiieh ia a glycoprotein synthaaisad in liwar
and pxaaant in plasma* fhia anayma ia SMcmg tha moat potent
ansyma of bo^f and has an anozmoua etpaeity to hydro lysa tho
drug into aocciayl sKoioeholina and cholina* rolfboa and
Morl»»n (itS4) ioiani that fhia rapid hydro lyaia occur a within
aoootwl aftar intraianous adminiatration of drug and infact
cuily aheot SX of drug raaefiea to action aita*

ioccinylmonoeholinaf 12% ua produead* ia also but a
waak nourooinsettlar bloclting^ agant imd slowly hydro lyaod
into . mmmdmic acid and eholiiia by a apocif i« onittin (dtooanfiy
ood dooftal* ttiil * „ ^ '

'• '/iiiMio' thnrO' Iwdli'’#i'>laa^ oholinodtoraoo nt
tnotanr mA plato lim aotii^ of drug in totmiMitod by itn

s

if fusion away tmm laaiuco-mascailair Jimction to tha axtra*
callular fluid and by radiatsibution to tlnw livsjr* splaau
kidiiay# liuacla and plaaftia. Only i^out 2li6 of drug 1«
exeratad thtough kid nays ixnohaaigad.

^kalln hydxolysi«f a ncNn*«n«yfMitiic
also occurs but it is sxtratNily slow and only 5% of drug/br«
is listabolissd by tbis routs (kalow# 1959) «

dttxm thonitip acts as agonist at isworo^miscnilar
Junction over ths jxist^Juiactioiial rse^tors« ipseialissd
aodiw ehanosls liiicli consists of ii|H»jprotsin molsculss
smbodsd in call mtabrana ctf siotor and plats* fiaeb raeaptor
contains two al|iia« ana bata* ona giwna and ona dalta sub*
units* kiMin soxiMsthoiiiinii molaculas oewupy feotk of alj^a
sub-mi to otHar Hiraa rotata to fom a naw contifiiratian*

AS a ramlt cbiiinal bacosta to t^an to allow baVca'^'^ iafluai
and K*** afflux according to imic coSMsantration grndiant*

Ibis ionic JtaaintanQMisnt causas srolosMiad danolarinstion af
waak intsaaity at tba . wotor and plat# to initlata pxopafatiiry
iopulaa all ovar tba siusolo iibraa*

4^JMia aunaiaitlioiiltiss stofo at wau wi ' ‘"wniaf iil i i ir junctisii
lonoar t ban ncaty Icbol iiia * b^ua <Smi nstot and nl a ta baoiaais '

dapo&axi>sntl.aii %rpa of as ag#-*i iwacul a r blosk ooowta laadiiiii

ill§''#|li^Sil*tol ff§| | HW l l#y ^Mil ''^1^ MMMik iJI

B

I. w)cei;rrarar« of €«8€l€mla%l<»is«

2« du»t9lm€i ainglft or tmtmic twitch height#

3» Absoiice of poot-totwnic fucicislation#

«• / Tj »«tlo I 7,t

S. PotohtiatioR of isIoeJc hr aoti^ehoXihcataraaas#

••g» MaoatifieliMt •

Faaeieuiatioiis are olasarvaO viauftiir# oooh aftar
suximsthoniian i^miniatratioiiSf a» traasiaot and loeo-ordioatai

wMuioolar twitch** ii*o«ilr f^®*# liwfc* oai *fed©»iaal
iRu*oi*»« mtoiisihr variabl* and ra»g*» fion fnini»i*l.

•urfae* twitching of ofoiid* or fing«r* t* oiid ox vodorat*
g«Miraii**d coar** twitch** <^t«a •••oeiatoi with iiMb
laowoiMint** Oeoaoioiiai ooeturm* of wigoxow* inooordinat*#
•hakiiig of tfoah laid ojctroiiiiti** 1* aiao not mmmmm,
how*w*r int**** taor ^ *oh*id* *• «»ofi •• *iii**til*r

r*iaii«tion mpmxvmmm imxmtg not*# Itat} »

Vioihlo dogroo of faaoioaiation* tiagr noil h* •
oharaotMTiatio «i m isdiwidiaai inaaolo hut i* ala* masifiad
hr tiiiolifiaMi of timmm ixitmra at al#

and hr # 1 * rata of praaoBtattiem of tha drag at iiittio«<*iiiii*«Blar
jaaatioii*' ' hapld ouraaiatt^ tlwa of patiaiit or ripid

'idth

aifOiwiMi f aaiiaiilatl.oo^ ^^owinoi« loMn# ^ 4ti#l whlJa, alow
ia|of Mon , ;ilif fo^fUr ;f i fanal^nilation . ^ liWMoal

•t al« titil 9 dHwloiiMf# OM# of o aato w ' titaiiito A* aMo

1 0

iff^rtAnt . «» water an4 MiiqpiaaDn (1971) liava otearwa^l aavara
faaeicru3.ati«»i Imt €»f ahartar duratioct aft«r a Imlm #f
longer doaa» ThiopHatona indue tion la alao kaewn to
ai^ppraaa the iaaeleuiation (Burtlaa# funitall.# 1961 and
Craig* 1964).

Etiology ot faaoieulatima ia atill in eontrorarior •
Initially l^aridaen and lichardaon (I9ii) fNtatalatad aura-
(ratik«Haiiiff indue ad metcuc unit atiimilatiim to te a eauaatira
factor* iiatar lanridaon (1956) oiaaarvad tliat atintulation
of «ran a aingla aotor and plate 'activate idtola mot cur wiit
through the antidroaiatic axon reflex:*

Patou (19 Si) haa aode another hypothe aia maggeatii^
that auxamathoaiuiii atiwiilate ietrafnaal filnrea reaiilting
into aaataiaed ooetraeture of ouaela apiixS^a ehieh in tnra
generate a aeriea of notor caiit dieeharge loading to
devaloieoiit of faaeioulatima* ' Eato at al (Hii) alao
eupported thia neoliattiap*

At jpaeiwMt eoneept of pre<»i ant tiMnl reeeptor
reepooee to eaxeinathontiee ie moat aoeeptii»la« a ai«wiNir CMf
gaanta of aaetylehoUria are w^oeed to le relaaoed doe to
thia reapciiaa and aet over motor end pXmm to proiimo^ the
faeoicwlatioe (lateaiore* T<Miiie ei^ degialii* lift) •

/ I' jPlilJLiAlliJil Hi Ik. • HilL .tf iHttiiiM,, "f

"OOMpioep volontoore eoon in alieeneo of'
eoy oiiiial oifn ind tdnoiUl ■icntitoriiig liee teen foond

inmSaiquat* in thm &mgwm9 of <!• polarisation d£

iMOtor ond plat* lortlaa# Timatall £3*etn»-

i^^raphi* raefjcdini has I3 b*ii eamldmm^ to J»* a tattwr
altarnat* iP^ard* Manfard# tiarria# 1971K

ft*c*ntly Janaan «id Hanaan (1979) hat* s«cc««d#4
in dairalopwtiit of an alactrenlc davlc* to monitor th*
faacloulationa by raeordinf tlw variation in arm
airaokofaraoea* f**e4(«il*tlofi* «iii*iiti£l*d idth aiadh an
alactronia oountar liaaa ahoan daf3.nita oorralation
tlw niaitears of viaibla c^wta*

ftMit»afMiralda* »y*lfl4i» Irtiaa- raaalsad fraqaant and
unplaaaant affaat of awaai* ^loniaii* :Tli*y aara raaoswiaad
soon aftar Intiodnatioa of tho dm® in eliniaal jcaetla**
Dardal« Tbaalaff ii9S3) draw attantlmi and mmm, colliaa
-and samara (19i3> anggaatad anacasatboaiiifii aa a poaaibla
aaua* far amen pains* sangar at al Ci9$3) ralatad iftam to
tlia iia* of all dopolarisin® miSGla ralaxant*

datura of pain roiNgiRblaa aith tlwt ooetur aftav
aiolottt and aigosoa* aamroisa of nnaaonatoamd smaolaa
iiioatlMiiPiala# nifioiw and li« iiilliaaa# tPiti ^fod ifiita* Itdll
tatimata maor d*a««ilfa paiiMi and.atifiMias lilm anffariag
fiwa Ha m -idH taat^lHaV'" baa# maalad riMMiii ^ ^ '

12

c&mmon mvm tim i>h«»tild«re# interior

olmst wall.# 19INIX' ciiiaat c«g« and mppar aiNI#min
in tliat ordar iBnrtlan# TnnntalX* ftiiiawai br «h« :

Jaw# linb omstoii# 19 €2) and tippair and lawav ba«k

(A'Arbrook# fianoa# 19B0I • msm n^xmt ia

alao aonaidarad to bt a paat of pain vfu&mm aa it ia a
raault of aiailar atioio^f Cianron# K.# capon at al# liil) •

£■:

■i

intanaitf of pain wairy **»•» mlM mimm to atwmtm
inoapacitativa pain at a ainpla oa aatitipia aitaa (Bnrtiaa#
Tuna tali# . 1961) • nmy mm praoipltatad or axaptn^ttad idian
niuacia ia uaad dwrinf mowaBant and mom mimmolf xrnmtn
localiaad at oaa or two aitaa (Nnita# 1962)* Jboaaiiaad
mmxm pain waF oioio Fiaiuritr Cduria# if §3) or naniatitia
(Pirioa# 1994} •

Onaat of pain liaa be^ inland to rawain within
24 lira (partorooli# 19691 to 49 lira CHaldin PalaNir# if ill *
but ocoaaionai patianta aiagr auffar within > lira icaraif #

1964) or aftor 96 lira (Bortlaa at al#«l96i)* Paina ipmolly
paraiata for » <U«ra i&iiita# 19it and parterook# 1960) tent
nap ranain far iB»to 6 daps iBwrtloa# 1961) • Xnapita of
wariiidilo oaaat* ' it ia nlNoat oortain that inoidanao ia
hiphar aftor oi^p .mismlmklm aa aia«goatod Igr c« mefiAmm
(ifSii* imrtloa* tonatali lltii) hawo found ^Mpalfia in^ ftK
patianta "tho iMooao on lat dor M3m it 'won loan

d4f^ of ORlNiiation o»9* ii% on Ini diff Mid 4711

. 1 ■> I-;! ’'14*. : ^ 'f 4 „ . ;

‘iMi Smd dliir * ' ' '

wSr ’Ipi HHPr ^Wi|E ^

13

Reportfttil ifteii3«nc« of n^algia ia not uniform
ramges fmm 1*2% Ccrawford# lf7l) to B9% {rajrthofar# If Si) •
Otiior raports )%«▼• auggoatod aa uMar i 2S% (Kagar*

40% CPdoea lOiita# 19S7)« 75% (Siieharia Bortlatf If 41) *
iS% (Foatar# 1960)# 41% (forxaa at al« Ifil) and $2% (Mj^gaa
and fotoinaon# 1987) •

naiaa idda iraxriatlona «ra thouglit to ttai jraMiit
of infltianea of aaaaral faol»»ra mlileh locliala patlanta aga# i
aax# naaaettlar fitnaaa* oatora lad duration of aurgary# ;

poaitimi daring ofaratioa* trpa of pramadioation# induotion
led noda of adniniatratioii of atijiaiiotli«aiii»R* flai mmmr of

' , E

quaationing for HiatoiF of pain and auloaqiiant raat^onaa frcan
tha patiant nay alao altar tta raanlta* :

' r

cSiiidran «»d patiant a oaar SO yaara ara laaa pconi

I

to hara n^algia ilnan 4* B&th, 1961)* luriilaa# Timatall

■■

il96i) haaa ofeaarvad laaa ayalgia C2*i90 in patianta of tnora
ttian 60 yaara i^a* Moording to mind 6 firyaon (lf8S)
ehildron hmm wmm alaatio eollag^ fiHraa ao ara laaa pioni
to wiaola ipiiMilo daniaga» ' - .

i#aati»aidala at al (i960) tiaaa obaaraad )ii#iar
inoidanoa in fanalaa in oonpariaon to nalaa# in m& ratio '
of "l t 'l ifitilo tetlaa ot al (Ifii) ri^iortad a fragoanoy of
if% in fonalaa and '49% m^rnaao* aiding (}f7S) and Mi^po#
MdfiooO''^ 1987) alao 'tiioo^ ^^aaroad’HitiiM iaaidinao in iaoaloa*
Moat i,mmu§a^9' mm aioaad tout yootor' (i94i)'lMia foaadl

M aifiigiiiMMaiia jyii'''jyatidoaoNi’^'.4Ma Hm toaaia of aim*

14

AjLtberagli f«tntJL«a t«»d to h* iiighlr to

dovoJLop i^Alglii* jprogoancf !%«• a protoetlvo rolm against
this taodsncy (caraifford* lf71) and it iRay too ioipt ,
aqaliralont to proouraarisatioo with S lag ttatoocrwr arias m
40 ng <i»aliiiRi£» (Dixtta st ml*

crwifori {lf7i> «3iw:l.uas<S that pragnant wotnan
ara SO'^ lass sttfO'Wpti tola liiaa thair aoh^pragnant eouatsr*
parts* parhaps toaeauss:o£ high pmgmmtmt&m oonc filtration
in tha tiastts pwwwats wosola Saaafa litM to suxamiliioniawi*
Alsiost siaiilar otosarratiosis wars mkSs toy Patta* croototr mA
Alpar (1977) ahaa thay #Bta<ot«di lass easas of sarara
faseiTOlation (29X) and n^aifla CaHtS) in prafoant wosan
whan eoaq^rad to fasaicralatiaa Cfitud and aiyalgia (il%)
occur ing in iw»n*pragnint •- postulatad tha rnpM

itilutiini of suxfiMtthoaitm toocausa of hi^wr plasmt wolmwis

Sffiaaoy of pragnaadir aaa confirwad toy thind and
Bryson I19i3) iho haws daseritosd faseiouiatio&s (BS»'7^ and
nyalgia C7«f%) in prapisnt to tot significantly lowar than
noa*pragnigit who had faseicttlations f7*d% and ayalfia
Shis tinn castsogan was phitulstad to toa ptotactiwa agant
against tha siinasnlhoninM indwcad anisela Ammgm*

t-‘', . 1 ,h _ ‘ '* ^ ' . , .

^ mmMmm (I9I4) has dascritosd hig^r incidmca in
nwt patients (diid than in-pa tisnts (14sg«> Morris d omm
CIS If I mmA this ratio to tos 7t i' ii# mmmAtm

at al iMrtans* fnnstaU (iSiSI md »•€*' Hitta (i»iD

?il«o hmrm «upix>rt«d th« vimw that ajm mor®

8ii»c®ptible to hav® mjraigia thty t«f%4 to rapttln

idobii® idiil* iaNi«ll.y prafar r^eunteney dwriai

poat-opdtratiT® period* Xo cK^ntreet# frie^ «t «1
end Boonette* IdnaiiX Ci981) obeerved no differeoo* tsetwooia
two f sroupB •

Morrie Dimo (2.957) «od Leetherdal# (19S9) imv ^

reportod definite reietionehip between incidence of e^eigie :
end the i^yeicel fitness .end ntiyioie poirer but Hiddin Pelfies' |
(29€2} sticered increased tendency of ag^slgia in patients witb |
Jess deeeioped smsciiietwte* NeimeRt & Loiftdbn (i9§i) baiw I

mmphmalmmd tliat mmamlme fitness is an inpcerteat f settee nd ;
isyaigis is less iiloiiy in patients with food initiwlar fltasss* |

Mapte and Bobinaon (1987) have sstablisliad the sole
of muiaatier fitness when they were able to redtee incidence
of wfalfia ftosi $M% to 12K by pretreatiaf patients with

eSw. 'ttflbJ&iii -slhL .Mungiu jMsi ^lMik.)teidfei'jiUtt;.iiiliilhiSi^ A stfw. ewk .WSSi iitm Wati at -Jku lUsLiSM iSnii jido^ iiMi' -m i iitfliBT litijiTlii^i

Xstwre If epsraticsi also inf Iwmces tha nfalfis by_
daterpinisif tha length of swrgery and tha poaitioe of
patiant* Pain ikC aergfssy sugr iiaa)i the en ¥a--paliii and it
oi^ be super imposed over saws sits* mtimtrn aftsr nlneer
siurgpiry ootmet wiiiiat*pains easily bsoinaie it my is omnso
sofoto than Hiat ^^retleni' (cralg* Ifii)*

le

Vnmecmt&md «ii<$ j^ition* piwdueii

Qvn ^paitm •• 9 t. higliwr incMmc« of lorn Ttmckmoho aft«r
iitliotovny position oxm kmnrn*

timozimm of it»aiaa i

Tim 9xmt mmdOmS.m &£ onxmmtimniwm jgmim zmoim
mfa^ziomMrn XnitialXy tlittV hav* b««n mmH&9Xm4 to Is*
rolatod to ocourrmco of iri»lbX« faacicuintioni (D«ri<l«oo*
19S4)« md iocidmem of ofinrot# paliMi wot# ottiibtttod to tlw
vigotoiis f*a«ico lotion* (B«nnik*« 19M) •

{^orri*# Puim Cl9S7)«’ loot^jrdal* mt ad (1999) mdi
Tiin*t«ll (1991) ooAttaMSictod mf »och eormiationtliip
«ndi ovatn vifojcoo* f«*ei<ml*tioa of «liort terotion kovo toooo
otooorood to )9* oooooiatod vitli codostioii i» ioeidaiieo and
mwmzitf of wiaMaaltiQmiiaR poin* (Hoidiii and JPidiias'# 1991) •

(Solsoa^iaaotljf nost of tin* inroatifotor* iadlod to
ostablioli ttMi «N»*jrol«%icNo*lii.p IsotiMiwai oeootiroaoo of »tmm*
wMiliioiiii** fauwloftiotioiio and (wiiito#* 19921

Coillojr* lifif aiogoat ot «1« HTf# ' iooiMtiMi aiid idMi&il*' ItMi
foirso* ot ol« 1999) »'

Motaur* Na^loaoa (1971) Onto jpoMitiilataKl tt^nt flmiv
fmioiimlotioo imimm wmm wmm^m 4mmigm d«Mi IM* imxmmm
In stMilMijr of oltoo of idioofiop ibsoo lotifooii mmoIo

„ "■ ^ ' '

' . IflliWUTCIOlilli 'MlidlOOlMM tOOO lOOtO INMtlllotOti tO OtplolO

tlio fHiooif ff owM ip of oiKiOioiyiaKiK&ioii polm* '

17

!• Lactic acid productloR as a rasuit of vIqoxoos
fasoiculations (Von Konig* 1996} m

2 m j^ecunuiatioii of siaccioyiHoonocdioiiiM (Patau# 195B} •

!• Fotassiuw ralaaaa fson tha ffiuacias (Mi^rliofar# 1969} *

4« nsJUtasa of ietrinaie algogaaic siatatoneas into tlia
axtra-cai Itiiair fluid has btan poatulatad hf IMiala and
Hail (1974) • Mam of tiiaaa sulMttiaseas mtm thouQnt to
Tm AmMmBmt AmBmPm, AmVmSfmm HiStatrilUl OOd S eatiOlliC
protain fioP tiia laueocjftaa*

9m Prostaglandin asrotliaais isid ralaaaa an^r las an iaportaat
factor (liaiQUil»# lit?) • ' . '

6m Mnsfitnlar tiaaua damsga dua to uni^naiinoiiiaad mmtxmtlom
is tiia Most acc»pti^la factor# althoogii mdlkmim and
sita of aauicla danaga rsaiiins mrntmvmfimlm

watar & Maplaaon (1971} iiaaa h^ol^aaiwid tliat
raacliaa diffariait «i|t»iil>rila at diffarant
ti«aa as taaonlar supply of adjaeant fil^as smy oat Is

4Mi ffm 0i jlirkv^s #09iiir9 i^ni%

' ' I'.' , . ‘ -V 5 ' ’.t ft ' <,/ , - ' ’'/• ' ’4 ■ \ '

IMIif fe lt i9ili|ilHi ' VMiwJto £4INK'|M ' 4iii4l

JIMiimMi'liillllMA# i#»i.Jhk Jt tmt S mmmmm Ji. mtm^ UIIm# UdMk iHAim JSH UMiii

^^0

hWMStWm

18

Colli«r (1975) hmm BRuacXa

dmwagtt to hn tha priKarily raapottaitoia to emmm Muxtir-
fMitJioniwi pain** Thl» aita a««»a to bt raaaonttola baaaoa*
woat eoiRiRcmlT' paiaa aaa mitad in tha aitaalaa biviag liif)i
4piadl« cotmta a»9* fftuaclaa of back of mek, lomms thorMlo
caga*

I^xavaraibla ehangaa in miiael# apindlaa followiag
admioiatratioo hava baao fooiid and ara '
Attribittad to tba iwicli«alieai damga io tha apiodia atructiira
(Ri»:)c I9d5> • Ibla braaltafa iwif itaalf jraaolt

from ability of aoxipwthociliai to piodtyMsa amataiaed
- mmtxmtmtmm of tba apii»dla fibraa doa t» atimalatiflai of
iotrafmaal fibraa (Maaov at 'Ol# '19it) •

Maadoaa (1971) haa obaarrad tataay io ^iMIaa to
OCCWf aftar ttia high fraguabey of aotioa potantial gaaMaratiOB
at irotor and plata by tha annamathoaiiia* colllar (197S) haa
mora appropriataly aufgaatad oritioal thraaliold frafatakOf aC
aaitor ■mlt diaaikarfa to ropain 90 Ha aftar idtich ig»iiid3aa
ocmtraotiHra aad daimaga ia laoit IDaily to oeoor*

Moaola apifkdla danoga aa a evmx of mmmmthmliim
paim alao awplaiaa tha ooaorrahoa of poat««paratiao aoro

tlibi IP % iiWihthi-Mi Mm % .Mo. dib- iMOdlb IKite lik idt iMk Ibk. fC -a*** Iba -inm iiiiaiiii ift iilkjillfc « . i jlFiiilMti'TlIilitfr - oth il Abriiite ,

IwSWIlt# Ml IMiiNtjMIS MUiMmIPI mA^m WUms^WW^

imMmmm, #f •mMmmrnmlwm pMla mm mt

jpi9® fr**^|pMF

'ii.v % ' ' -'I/'" . ’ :

1.11 imi M i # t Iftyii ' tjay». di ^ £lltt UMPiMiiifc

pPP wPPI loUppriSlppR fl|p|pj|^^, ’^ppiPd®"' lOak' iWPaP^P PW' "WwIPPWiPr *9PP^9P^Ppi 'SWff'

■ Alt amtlv ' aadailjitioo aaiJdLod* 'fboa* ovaratratiiiljiii of

•«. ^ mm w#. wwmmvw^ .

XB

9imil»r to that «ft«r irigoioiii «3ctrcis«» litif &ceixp •which
«r« subseiittaiitly ractognisad m» analgia*

KJiiapp* icoMngar aad Kmpp (If S4) « in •niffiaX
axpariawnta# has dwM^tratad anridanca af doaa <N>paadaiit
risa in piaama potaaaimn coneant cation altar aujcwaitlioniiaii ^
aiminiatraticm* dinca than auxamethonim ia wail kaowin to
poaaaaa tlia pcopartf to imluea a niid and trtnaiant riaa in
tha plaaffta potaaaimi ooixsantration which rasHiaa from 0*09
m iml/h (Liat* 1967) to 0*66 m iml/h dcuMar at al« 1997)#
iMsira than pca^indiKstion walna* Paah lawala aca caaehad
within 7 miaittaa (Maiatc«al»# tiaiatarlcniiqp and cc^parmin# 1949)
and uanailjr paralat opto 19 minwiaa (Bali# i^mdaa# 1974#

; fihatta at al# 1991) or awaa vpto 1$ oinutaa iumm at al#

1949# Koaciiigari at al# 1974# daaaal at al# 1974) •

#atoa il9S4|# l«iat (1947)# fttrikar# Marrow (19iS)«

MumA at ai (1972)# lali# Moiaa (1974)# Shatta at al (1991)
it Mifaa at al CS99I) alao hawa cMClmlad that thia hfpar* |

, #«#«». ««r. .*.«

1

Tha aaaat aaflhaaiaai oi auoh hfp»iwlm3mmi.€ raipoiiaa j
xmmkm iMi'mt&thXf* howatar# it im aartain that aiMla MaaiM ‘
mtm' m mimm'&i jpotaaatiiii (tahaai# 1994# Bali# MMMiaa# 1974)#
^ia iralaaaa liaa 9aa» att^cihiikai to groaa taiMtalar fatal*

Ifcllitf# MiiAltta' i^SI

7ippp^p?4||f9i upp 'Bap’papppF tMnK|||19r 7PF 9119 Wr ^ apar wiippp fPir tfpspapp liua^i . aiiii 'pjPF aapr W P tp , awnj" ijibmw ppa 'Mp

^0 ;

®irid@nc« also has suggsstad tliat »«acl« dawaga du« to
faseicuiation wmy induca la ale of intr«*callular tffiisela
eontaists such as eraatinina i^osphokinasa and m$'oyiofclia
iToamiato# Mrakalnin (19S7}« Eoth and Ithxtihrieh {1961}
haira postulatad that potaaidiiis is raiaasad imn tha musela
cells due to call swfehraiie iajurf during tha dairalopmiht of
shearing force feetwaan tha miscles calls at ttMi timi of
faseiculations*: -

Ms^rhofar CliSf) and Magah at al (197$) have
raaiawad tha hi^po^ sis regarding tascioulatiofi induced
muscla dsffaga hut iso siicroseopie aaldancas ware concludad to
prove such a dsmaga* Jaasal at al (if 74) alao failed to
•stshliah mf c^rralationOhip between mmmimthmimt induced
fasciculations and hjowrltalaifiia* iHoraovar# dohn end lOhsiT
(197$) have rs^ortad caaaa of isasaiwa hsrssarlialaffiic raoponaa
even in ahaeoca of wisiMa fasciculatioiiaa wintrauh at al
(19$9) have O'haarwad aguivalant hfpaskalasiia with Wm
SKisawathcsiiiani sod daosHiaidionitm idiila later resulted into
wtniiRal f asoiralationa •>

Zt has hsan postulated that *dapoliriaaticm of tmf
ascitaisla atastaraiia ganarallT' J^ada to potassiwi release
frost the -Call oonoarikad* (PalMii* 19S9) • Paton (19S9) *

te. .dsi^^swik. ^saito m ^ difll M 41 IK, ■ Jdih- iliPt' iihfii i I'lilf iiminMIliin iiWiiitfillii usi^ifrilhr astei^Jlk

%WwWmt mmWm

jJi,«ii«L, MmM, illlkllt lihiurfilit imiMk ^ df |g||l|l|t iHi iM jMlhlHk d d Muk ,.Sfc k,A. ..aiiifc .. JQ aSl Jlfc. ajUii.. jilllfc,i % mkHMM Jl «aik..itia. J| '

l^pOiPiMI W

votmnBlmi xmlmmm has tsssn «i»]^oss4 tm

wry is row as

mmh fwiscuis of smamsthotiw 99^ aimplmm about IC

itfhiis omlf S^i& cm bt dispisesd by s molaculs of
acstylchoiiiMi*

proessssd (fsun# 1940) •

hist il9§7} has obssrwd* sitsr th« thioptstofii
loauetion# ths sigoiflesst fail, in tha iMsa piaasia potaasimii
ooneantratlon tmw 4miQ w m»l/Li to 3 *91 m m>l/h (swan faii
0«39 iR sKiJ/b) # but tha subaaquant atiwinistration of
auasHNithoiiiiia raisa^ tha maan potaaaiusi ooiiaaBtraMoo to '
twoowa 3*t0 m wml/i, to proauoa tha naan riaa of O»0f w mi/hm
C^iioeiiaatJLir# tha tMan riaa* aftar tha auaasothoniiM* mm
obsaraafi to la w mcl/h uhan Hia ia4uistioii was pa«ionMi9
witli tba ii|ai»ira of b^O a baiotliana*

Mattab'at al '(I9i9) haw ihowfi swan plmmm- potaaaluRi
aoiMiaatvati«a to tiao'ii^ iim*iaiuatioa .walua of )«i. w moI^
to baaoaio^4«i '» atol/t;, 4fi€,4^ini«utaa)« 4«i' Cat,i^^ .

.4^'% wtd/h 7fat;.l0_.,ati4 IS atfiitisa# uitii

ww ^ wimiiiMii' Wmm^ OX v#o w iipjyFii 19 oociur#

> *

• ^2 :

Millar* wajf* ffiriitoat Itaivar (1972) alao lia««

Ml-iQwn grtrilual atiataimid c^atiga in i^rtasidifft lavai f*»iii
3«7 m m»l/h to 3oi (at 2 iiio»t«a) * 4*0 (at 9 ndtutaa) anlt
3»a m ik>JL/ 1» «t 7 and 10 ndnutaa* vith l^a liiaciiiiMR fiaa #f
0*13 SI ftol/I* at S minataa*

iconchigari at al (IS 73) hata rafportad tlia naan
piaama jpotaaaiim ci@;M:aiitratiOii to ba 3*59 » mol/L (pra*
induction)* 3*99 (at 2 niUctutea) * 3 • SI (at 3 wdnutm) » 3*33
(at 5 inlnutaa) * 3*36 (at IS tnlnutaa) and 3*94 (at IS winiitaa)
aftar tha adtriniatration of auxamtinoniupt.

daaaal at al (1974) ha^ miaanrad- tiwa naan plaaisa
potaasiwt ooiKMitritiOii to riaa from 4 *40 m iml/L (pca«
induction) to 4«S at tba tismi of faaoiciilatloaa* Tha
potaaaiuin laval again raiaad to 4*31 w w&l/h at 9 pinutaa
and 4*91 at iS minutaa*

Ttiatta at al (1931) hava iHoifn a riaa of 9*1 m wa%/h
toatiiaaii 3 •* 9 adjutaa ami of O*! m m»l/h at ttai intacval of
1© nin ai taa # ■ ■

Maguili at al (1997) Imaa tlbmm t^ia riaa to ta of
9«1 m ml/l at > oimitaa Imt ma potaaaiuo laoal ratumad
to pra^^iiidiietiott traliia of 9*9 m ml/h* ■. ""

KiiiMir at al (1937) .alao liaira obaarvad a tiaa of
9«ii o'liol/b dboa tbo iwiii 'potaoaiiopt lairala vaa raioid imm'

^ ■. .Usr4 .-i.i 4 ■' '' ' ^ ' ■ •

$•§• m Mol/b to 4a9i"ii oiol/l» at tba iataroal off winiitaa*' '

Xlw tiDizal niia in e&nemtrmtk&m

it of littl* ciiitioai sipaificoneo in iitoJLtitf potitato
hut tlio •uaiiMtfiooitiP wir indtieo wmuhLrm hjptxMlmmiM
in oortnin fu«Oi$>titoi« pntlnntn mifforing ftoiR Inann#
t«t«iinsv minnivo trnusMi# M!mr®a4»gieiii 4i«or4«r« ineindiiaill
mppmx nnd ioiror mmom ^norvation iajiirion and

chronic r«n«X faiitarc* In mi^h ««••• pioiifui p&tmtmium
ctmccntrction havo Imnii rai^portcd to increase caren iriboare :
thtt level of 10 m mol/h nhich is wifficiont to cause fatal
ventricular arrytliiRia ioronert* 3tiie|e» 197i and Inatauki
«t al# IfiO) •

Xn fact# tmmx&u* ineidencea of tnea^lained cardiac
arrest ha^ ramdisid assoeiated with the iadiaction of
•naastihesia* forrest (19 St) susjoaotad suximitlisfiituR to he
a proMhle causa of thesa cayrdiao arrast* wora ayppropriatelf
fiiwir and Mflan (liSl) attrilsulwd tlwntt to tha hTperlialeiRic
response to awixaMitlioniiim* ' l>avis et si (if il) ma alien
et al iitdl) also rsported cccurrsncs of fatal cardiac
mxythmimB in patients ahowing ii»ssive liQriwrlialaHiic re^p«iisa
to 111 M liiiia' * * *****'

^acewrding to arfmeirt il97S)» only ix loss of total
potassinRt content, of ■innonla.r. nass sNijf mif f icientlf , adiiavc
tha piMmm potassiSMi mtmmhemtiom t& rlsa ahora 10 n ml/hm
Stital jaao iuiatimiit ' tii' cilct&latsd' in an sfveraiMi'

if# '''it*) iNitisiit li^iiiMiidn^ ' lach l@#

#ns, total ^ :

jwi% i i s ii! | ,;iiiia’ 'appitont wo*y'l4 %9t 14## n nolSt*

rmaln 7 « » •ol/t 1« • »>“«•« p*tl«nt.

•am imonum* .wewtiMiiW i» »««•»*•

. fc, «o th. —• *•“«• l“«— “•

I dl.uM .ttoidiir (Mi«. »«> «»«> *“•” •• *•

Iw* th» of oaoelo to roloooo owwooioo

* of oujiMtlianltai (omuort, 1#7S) .

lD«r» «r» isoat firoB* to e«r(fli*c •rr*»t

durii^ indtuction of onaosthooitt fettwaan 21at «a<3 Slat
pmt^hmm daya Ccawgliay, If 62) •

Tataaiia t

i^h m& Mu^iriah (if 69) haaa taper tad thia maaaiira
xm»pm»m in patianta of tatamia. mtaalva tranm and uxmml&*
In tha praaentad aarlaa of mch patianta# amiMi of thmm
ahowad i»c»c« Chang aa miggaatiaa of nyparkaianla* a tatwioa
caaa had dafinita riaa in plasma potaasinm ooncantration
ffom 3*3 m aol/l> to 9*4 m mol/L within 2 iid.ntxtaa of raeMilaJnif
suxwnathoniim* Similar highar plasma potaaaiuni eoncmatratiaft
(7*1 m mol/D was also maaaurad in a patlant of maaaiaa
trauma at tha tima of atixiMit)u»nim indtuead cardiac arrest*

Muscular daganaration and nacroaia occurs in tatanaa
patianta from aacond waak ommedm (Btirmmmm, 1967# Bica%
at al# 1967 «»d jQfrich# 1967) * Tliaaa patianta tend to
daaalop supar-aanaitirity of tha muselaa in rarponaa to
aeatylctkolina ac amranathoniun las^umg to hypar-raflarla
or j^fparkalaiiia rai^otiinaly* ' tha rlak of maaslaa hypar*
kalamia may poraiat for indafinita pariod or at laaat opto
6 monidia*

l^h at^al (1969) aatakliahad highar maeaptihiJUlty^
so aavaMp auxanatnoviaum rnoucad maasiao a|fpa0ca«a>ii.a in

patiants of oaaalTa oaaoular Injorlaa. In am* • paUan*.
plaao. potaaiiuo «ne.nt»«:lona «« ™aaut.<S to ba 7,1 ai -oI
at tlM Of aunaaothoniuo Indneod cardiao arraat.

Maaaa, at al (I9t9) alao ha»a raportad an incroaao
in potaaaium concantration fxoo 3.1 o >»l/b to 6,8 «
with naJClmw bf»o n* •** • aoVb In “®** patianta.

Labor. Kiiaa *ao at al 11976) r«-ortad oeonrranea
Of cardiac «:rythoia and ralatlaaly I-:*. byi-rtaLaric
raaponaa with tha riaa of "7 1 a. a»llL at about 7 ailnutoa

mftmx xmcmiving suxwaithaiiuwo

OMaa patianta ha« baan anppoaad to daaaliw.
aupar-aanalUalty ICooparoan. 1970) *out I -a)- aftar
auatainlog tha injury and it paral.t. till eonplata haaltng
of -ounda iKaaaa at al. 1969) . Hoaoaar. rla). la .>lnla,lnod
durlns aouta phaa. of injury a. Chari, a hoprlaa at al (1971)
haaa .ucooaafuUy ad«inl**arad wwaaothanluo In aach p.tt«it
only to found a rtl«ht rlaa In plaaoa potaaaiu. cone«.trntlo«
t ♦ 0.4 - noVU. >“n patent, oar. «...th-tl.«« -ithln
) hcmir* ot piMitiiiaiim injiifl#**

A. Hid* viytiiitgr of maiciii**’

Mrnwmr* **•' imtinat* Umm HSiHiy

diaiw#ro ""

!• homx Motor oaosoimi losiona - ]Mn«nr«t«a injitrioa#
dogonorotions# MourosmtiiloAi 2* Vpp^f motor aturoiut
no *' cord iojorioa, snc«phmliti» * Cmx&hto-

...or Acoidonts* Koftd iojiiriosi S« Frolongod
ilisatioR - tmtiftomy* Zotornai or oKtoroal

;oxiSi 4* i^opftthloo* musealor trwxma «o<S dcgtoorotioiii*

Mtom ot «X (1970} ol)««rv«d « marisiid ri»« in plmmm

m paraplogie pationt* at thm 23rd aftar auataining apinal
cord inJuzY. ' Ra 3 rm>iid, Tolojr ( 1970} ' provad tha •tiaeaptibiXl.tlf
of jp«rii|>|jagia jpatianta aliaB aueh patlaota ihotfid plaama
ooneootraitioiia to ba 7.3 aod 11*0 m mol/h attar ti»a
admini strati on of 30 «od mg mxmmthmlm iaftisioa*

PaaJc laval of 13»d m mol/h aaa iNiaaurad but pitlant tiad a
cardiac arrast* coincidantalXy* potasaiiim eooeaiitratioa ia
blood draiiuid from Ximar ajctramitiaa latra maoh higtaar*

Cooparmao (1970) ctearvad an immadiata* pmxBlatm%
and marlead riaa in potasaium eonematration from 3*9 m m&l/h
to d«99 (at 3 miiiittaid* 9»0S (at $*S minutaa} mad i»5 (at
iX«S miaiitaa} aXcmgwitb tlia wall corraXatad s*C*0* cliimgaa
aftar mxmmthmim in tba patianta aiaffaring from mppar
motor naitreMiia iaaicm*

' Similar raaponaa baa baaa' raportad in a bamiplafie , :

patiant .(st9iMi,at/'al#’'^7Ci} ’ jUi wbicii potmtaiwi ooMantratitHi* '
maa raiaai tipoin f «i to ilaCii. molA mitbia mimitaa of
saNBoititev' a ntawa t lawaimai » • , ' ^ ^

cmglll, Lueill.* (1974) man plaarnfMi

potasaiw coBe«iitr«tior» to ahcai aii4 porsintmt

incr<>a«« fzoR« 3»S9 to 19*53 {mt 90 tocc’mt) « 7*39 (ot 5
minixtoa) «nd 4*13 f» wol/L («t M miiititoa) ia « eno<iC>liiOLiti<i

of elooeiS ^ad injuria* alno haaa alioiai
axagMiloratad hjpparkalaiRic r««|»onsa to auxanatiioniw
i^tavanwon and Birch* 1971 1 Frankailli ma uxwmoA (1997)*

i>ati®nts of various muscular disaiMiss such as
pi»udo-hfi»«rtroi>hic muscular dystrophy (Gsnsvsr* 1971) « •

myosarcomi (caizoli# IfiKI) and rhabdomyosarcoma (Laura at *i«
19^*^) ara also rcs»ortad to be susceptible to suxa^
hyperkalemia*

JUiaet fneehanism of increase in miae«f>tibility in
neurological patients is uncertain* Muscular tissue of such
patients are supposed to develop the neurotrqplc dhanges
similar to thoee «hi«h luie to caccur after denervation*
in the ease of upper motor neurone lesion* the loss of
higher centres influence 3Uiads 'to occurrence of trophic
changes at anterior horn cells in spinal cord to main the
lover motor neuroMi inactive (Gronert* 197i) * loss of
neuronal activity induces inpairment of mwdatmm ion
permeability Cthesleff*' lfi3) and totive i«Nn trioisport
(iDockcy* iPtfd) in the ^ muscle cell itombriiie^ leadiims bo
ojfceesiee leak of potf(ii||^uM . during chemical emcitation*,
kending ot al (|fl^|.„iMid kduiiir (1973) hove postulated
that entire . mmsci'le surf son become reaponsive to mmmrnthmiim*'

Gx^aort U97S) hair* suggnstaa id^at axtrajiinetioiMii nreaptcMra
d@*«Iop th« c^am>->a*hsitlirlt7' irntm^A of ronminiiig rnlaetm*-
•enai tiva oal.y'. Thm^ m %qvd.rt^9m i«asplti4do of
dapolariaation inii^ result into •xceasiva potanaiw off lux
from larger nnuioular aupar-a^isiti'ra area*

Mmilar auper-saoaitiirit:^ is alao x^iom to occur
duriiig prolongad diauaa of ioiuirvatad inuscla* Magoitudo of
l±ia raaponae remains mild to moderate be causa eiren minimal
aauzonal actiirity presaraes some muscle tomi and prevents
the trophic changes in mtaselea to occur* i^oraovart Ihasa
changes tend to return t^ards irarmal when muscle is refused
or external stimulation to the nerva is applied (Gronert* lt7S^

MmM. t

Moth et al (Idti) have reported ayn uremic patient
who showed significant rise in potassium concentration froM
d*S to @«9 m mol/L after stucamstliMium a^inistratioo*
similarly# Powell (if73> masured m inc'rease in potassium
concentrstion fiom 4*1 to d»f m ml/h*

How^ever# Millar and (If 73) have obsmrved no

I , !

slgnificsnt difference asoiif the uraemic and non-uraemic
patiente regerding this response as rise in potassium
oonceninriitioii iMPalJMNl' '.t 0»f m molA rejipeotivelf*

diwilarlr#' iseide 'end :ll4id|/ 'haare reposed onlf m fllgilt. ’

rise (' ^ til ,m m%/U. ] ';Oji.:.p |M| l pi ; potaneiiim' ooncentratiom im

so

InfctioM 1

KohI«chutt«r r<ipoirt«d this r««po08« in tlis

patients of seifsrs intrspsritoassl inf sotiofi# in «diieh
potssslur coiicsntirstl on wsjr# 4ncr*ss*d C + a*5 to +3*i m
«£t«r stjpcmNithoiiiitS)*

khsn «nd hsTS sttribtitsd th« mmgnitvAm

of hypsrltslswic rssponss '!» ttis s«^«rity «ijd dorstion of
infections and najcimun hypairiaiiavRia occurs bitvaan 8 • 2i
days a£t«r smvexm infection. Bisa in saruw potassium ieireJLs
were found to ^ary within range of 0*2 * 2«3 m ml/L
depending upon severity of inflation.

M.vmire'Ut ineasiires been ipplied to present

suxisrtethoniiim induced faeclouietitsie# fi^elgia and
hyperkalemie*

!• ^oeeinyl bromide in place of suecinyietioline has been
said to induce less tvyalgia CBudell et al« 19 Si) but m
significant di£fer«ace was ol^erwed by iUiatiisrdale et al

C1959) t

2* duxe-HsttioniisM eubstitution for suximitlicniiiPR has beon
suggosted JMlerby (29 $9) but Farbrook and Fiarce
(1960) contradleted tbia oiew.

I# diMifiga in foato of loiiiMotboniuiiR adminiatration from
intraoaotous bi 'ijOitilMOiilitiyiir waa not found 'to Ini "f wt f'
o'ffOitioa ad oyalfia wmm 2i#i ^4 2i«iK

3l

4 , Swxaiwthionlmwi «• ailoif l.v. i»fia«ion (0*2'# Ji*» bi«0
found to Jtodiactt inoldono# of from 4Q% to 14%

(LcMioxroax »t itl« lt€0) i, )3«ieau«« onlif initial axpoatiro
to th« dxug iiKSueoa th« mncln d«na^ and raiati^raljr
iasa myalgia (Motor k Maploaon# t97l) « hm^'wmr Mhita
(1962) Daa obaarvad raduction in f aaeioulations Mitb
this procadurs but incidanes of myalgia raimi nod Ulriaf f ootti^oJ

5. ilOM l.V. adwlfiiatration as a singi® dose has remain
ineffaetiire (rorris 1957) * Mouamar, rapid

injection of larger dose of auaamethociiur has ledueed
the suxa-paiiis but associated with the mmm sees re
faacioulations (Haidin Palner# 1961) •

6* Self T«eing by using small doaa of auJcmnithciiiiiOT (10 mg*)
prior to the :&ill paralysing dose (1 to 1*5 mg/kg) has
been found effective in prevention of faseiculatiotts
(iaraba* 1977) but inhibition of syalgia ramaina
oontroveraial *

7* Henafluramium bromide (FoMes et al« 1941) # ehlor*

prcmasine (Iforria k Dumi# 19S7) « Atropine sulphite with

'■ 4 *.,‘ .

neostigmicMi (Foster# 194p) also have been used but
remains luisatis factory#

9* %lcN8ei!ie htn effaetivoljr redueed the incddauee of

: A -Si'UA.CV ./v' . I

myalfia* xt^oan,, bs.usod as^^ilnfle l/v bolus of t mgi/lisi.
lilpcMaiiMi^ tbMMiiifos I9f9) or as 1% x*v* infusion in
Ifio d»sO' of i«i ^ litoKin # . 11751 or as topioal sproF
Of oolol f^Nio of 'i§ * 110 mg

f • Vit«nin c lulffdiJistifAtioii «• SOO mg twin* oralljr
hmf&sm hft* •f£«ctiv« in f*jr«r«xiticm »f

eulAtiomi iaad pAlns but hypsrkdlitttio r«itid.iid

tiii«lt«irid »mm%t 3Lf7l md Mmmx tt id# 19W »

i0» Dmatsehumm !)*• sifnificaitly r#diie«d idl advdrMt
«f £«eti> ®f •iuc«mitlii»itim in tb* #d«« of IdO • ISO
oral 2 licwir* b«£oir« tb* iadiietioit of aiiftostiiosio
(coiifoir, ms) -

li* Mag«4*iii» aulpliata h«» lammn Mhmm to aboliah »»*••

f asciculationo and ri«« id |>l«siia potaatiuiR but i»»t fbo
»uuctt*p«in» (Aldrot*# 1970# fttvora# l»«3 lod ChaataidJt#
£ittitd««# 19%) •

i2* cadoiiMi fliwniibt •• 10b •©lotion in d©»o of 10 »1 2 •’9#
•low $mt to for « tb« indoetion hmw% to«a tooim to
•ffootividf rodiioo moroloio f»©«« dix to Sx •longwith
•ignifioant iaMbltion of brs>orItalaiBi« riwg^oa**
(Myriwaatava at al# 19S9]f •

IS. mturnmAm l^o^tonatiitat ©boat i miwmmit

prior to hm radoaad ofalgia itfOM §0% to

1«90# fa«a4a«lati©ii»; ai*d;.lw«rliaS»iiila (torio# Katlior#

I07»f ,iii»i»tor« and „.faiiorf » at al# l»7f) .

14. i^iiiw'’aia%l' aaii^iata''<iW/io*) iwa*teaat»itnt

S 'iRinata* ^i«r"to 'amaito'tiipkaw'ba aftootiaa to -

raiiioa iaaai fib to'' iSb aitik aiffaifloaat iabibitltoi

of iMjcaiMi^toMiitHk' toparbatobia Cbanaib at al# lf«ll •

33

irmop«at©i» indiictioa - ThiQff&ntom iaauction hma m v

dttfinit* mXm ag«lii»t siaJt**3p«i»» CByd4«l« .

i9f«) mnA (List, I9«7| itsrliaps

iMMittiass of its to todiiDO tiio aiaotaixs of

4f0PO^*timotiaii aitss ot aotor •ad pist« (w»f* List#l9<7j»

Burtlts «od Tuastmll h«v« prodiiesd

mdlrmt «oia«nc« to pxovw this $»rop«rty of thiopoatgo* •
laoidmioos of wmtm incr««»«d tmm 24% to 17%

wlioii oteiiiistratioa of •ojcomthoiiitMn wm dan* tafot«
iastoiMi of of tor tho iaj«ctioa of tOiofoatoa** fiiwilorlf#
Moairy L cr«ig (1904) Itmwm dooctibttd iR3fAl94.a iaeidoactt
to bm imxmmmmd f<o» i4 to 41% «ilMa tioo iataroal Ttmtmmn
•teiaistratioa of t2iiopsatoa« oad loxwNitliQnliai ia
iaejroluiod fion fow SiMoads to S mts* ftM iaeii4«ao« luaira
•howa formas ri»« to 96% idioa thiop«atoM i« riplasod
hf tii« liOlom«a« a« tii« iadactioa ogiwt*

iffoetio* wad ooasistaat foil ia plosino potoosiunt
coiioaatrotioii oli^ Imr* tmmXn oooooiatod altti m«
thiOfiiAtoao iadoetioa (Clootto m% ml $ 19949 Mldcim I*

*' '■ 'll 1. 'i

If 66| lioiatroab «t «1# If 6» • MoxiiMRi^ foil ia
potoiaiiMi ooaoaotrotiono Imui lM«a diowa to bo f *34
• ml/h {»«li 6. mmimm, Wfl or 0*21 m mi/h
(ltoiwlii«or4„«t,olt.J^f# ,lo4» moB tteo prn^Mrntmn

wtam »• foil f Ifoif iooiit , botoooii^ , .

1*4 miaiitoi ot ^ol, ^ .

List (1937) has r«|>9S'tsd that HiiaqEMitttMt
««iis«s at Ltast 7l( faU ia plaaMa piitaasiiiii mmmtxmMm*
l»fparliala«ie raasoasa to aaxawitiiofiiasi ia
alas aiiiiiiiisa«i eo^plaMy yaaviiitail Jtf tua

tfoiopaatOMi and alight h^paalcalaffia is howid

iS* Fraerux'iyriaaticai with tha aaa of anali doaas of a mO" - ^
daiKiiariaiiig moaeia ralajcaiita 1 to 4 ntimebaa priout to
aoxaaathoiiiom has ramainad parhaps tha most wldaiy UMad
Miaa'iura for pmwmtloa of Buxmmthonivm iodoead ads^raa
aff«Bta*

i*alf Tiioo t

miia torn daaoribaa tha prawaativa ataatira in
whieh amailar doaa of waxanothoniim itaaif ia adieifiiatarad*
as tha pra»traat»iant« for tha inhiMtion of aj^ar*affacta of
tha aabaaquant foil doaa of aoJcatMith onion*

1!hia ooaosqpt was first thooght and avaloatad t>f
Bortlaa 'and foaatail U9«D ifiaa 9 ng of anxanatlioiiittn wot
oonaidarad aa a pra-traatsatit anamia and fiam Jaat prior
to tim thiopantona# Imt awlsaagaant obaar rat ions wara not
aatiafa8t»ry#''""«ha'i»a4^«a of npaliia waa* ral^r,
aignifionitif fidaad''i<ii'iy^ ioWntroi patiaota to 75il#

In ' 'contrast r' Of ” i''m df ‘ dali aniiia rate ad '

tha iaciidi»«a"''lo 44)1.' '''''’illii'# Ilf wiO o^ that'aoan I

III

In fact, tnm tsinR salf was intri>diae«<! fef

laraka (If 77) atum Im r«iri«iNid mifiemf of pro-troatMint
with •mail do«« of suximitboxiiiiii and foiueid it offoctliro io
ottooiiatiag tho faoeioiaJUitioaa* fco^tfoatmiiik
adfRioistorod as 10 «ig of soaKaM^oaiim aftor tha thiopantoHi
hot I oiaota prior to tho fall paralysing dosa of ansa*
mllaoiiiim* This noasiars siaiiitainad His •Jeesllsat ralsjcatiim

and iatafeatioa eondition* ihs pra*traatinHnt with
d-l»tooeiirarini 3 og (3 winatas pri«Mr> sigiii£ic:antly al tarot

iBOStlf in tha iofiii of isinifRal fascial toitdhas* fienfsaar#
sail toninf iltosa itsalf indnoad wild fasoioalatioiis in
similar nnsihir of patiants (30lO

Sfiioaoy of soli tasdng in proaantloii of fasoi-
enlatiim was alM proaad whan 70n»a (if?f> avaltiatod tho
M^od to mtoilii* tiia'OiiJM»io«io»ti*i( induood riso'^in intro-* ■■
•oolar piwssiaro# ■ ooon.in ^»«asos

auto*«eiia«at doam (IQQ mi) of swciiiittlionioii*

hlUmwlMt Mali tMlJig Ooam pro#»e«d • fMi«i riso in iotr««
oeolAi: i^jrooooiro trmi li.t? mHg to 1>«9 mUg* Imfe :
•itI»soqoitiitl. 3 r of oiixMollioMtsi roMiimO ioo^m^olilo

to iodioeo my imxUmr xl$ mm OaXy om of twooty fivo
fotionto co!i;|,>I«inf!d of ttild ealf nmtelo poiii in poitt-
Oforotiiro loiriod mmh ioiror lucid «oe« of wfalgl* wm»
attJTlfcutod to hm tho of fact of Plasopam (IQ
promt dieiitioo •

irodokjr and Mx&chmmrn (1979) htiro •vaIiuit«N!l tiMi
•fficaer of oolf toolxi^ in proi^totioii of mMmmtlmaXMm point
but ouip to oooeXiido thlt notbod to on iaoff«MBtl'ro mm»
JHy'oXgio oocurod in 2931 of otoot vAiotlitr tbof woro pro*
troatod oitb ooXf toning or not* Moiromor* otooolotod
roXauxoticm woo found to bo odoquoto ond fooeXcuXotioiio woro
oooo onXf io i&% potionto of tor oocood dooo (!•§ «g/kgl of
ouxaint thoniiM* fbo froqooter of fooedouXotion*
oftor tlM firot (ooXf tooiog) dNaiWi, woo found to bo liH*

Colne IdootoXXp intonoil^ of wioibXo fooolouiotioiio woo to
liowo no roliMioi^ip with tiio XmiAmem mA ooooritf of
foot ouooMotliooiiiiR poioo* wifoioiao foooieuXotioo woro^ 0000-
i» 22% eoooo bift ooBo of tlioo liod my oroXfio* iiaiXXorlir#
iqfoXfio oeoturrod in potionto 1^0 woro froo fBOni<footticwXotiono

niXoon mid iModoo 1X900) oloo boro oliowod ooXf >
twiiin® to ronoiii: offootito to'^prowtnti'MO of foo«iint.|otloa* ^ ^

00 mmy mm^mm iSM-m0 but''

pwlew oo««yrjr«d in 4# 4t «<! 4%
mmB rnnjpvetivnif liinn m wm niMaiaKnind*

;i*;; Mtnir n«if trnlm* BBimsm ptAm mmm nHoiliiicd mA wmt

'''■ faU«n« (ii90 fmA Hdid mA rant (iid nuftarad with waAmtmtm

pBlm* iMidantIr ta csarraiatianiliip canid l» aattiiilaliad
laattiaan aaaarilgr vtaiMa faa«ian%atia«ia and accnrrwM*

•£ cfiralfia* ’ ■ ^ ■ , ' , , ■

itaccaMiftil ‘ f$‘: 9ummm4hm4m nmim%Utixm4

«»in»Mta«iid •atatoi illiy#- ppwl* ** ^ aalf-tipiii® al tlia ^

wir« mmammd to Jat 3«i, 3.7 md 3*7 m ml/h at t4»« roopocti^o

tifM iiitorvai of 3# S

10

Mofoo tfRia Gal]L«^h«r (1991} har« «aec««<i«4 In th«
Stxmwmtion of post msxano hirporkaloBiia witii thti mmli

%«iRin 9 1^0 mmm plaoM potassiosn eoncontratioiui ^ow«d •
t«id«nc^ to bo Immrmd «v«n Imam than tha pra-indiictioii
values. Tim aacond as>a« of auiciMlIiohiiiiR warn aaaooiated
with affuilJl Smmrmaam in plaspa potaaaiun e^mmtxatim
{0.22 nt mol/U within 1 minute. I^Uowed by a mmm oradual
decrease to zeaNSh upto the maximiiin fall of 0«2f m ml/h at
6 and 7 minutea* In control group, the potaasHwi
csoneentraticHi were aigaificMtly raised after auramithoiiiiim,
mean plasma fOtassiiwi eoscent rations i^owad a rise of 9«tl
m m&l/h at 1 minute t» reach «ie peak rise ef 9*23 at '■ '' ''

1 minutes*' - ' "

^^ treuieiisly^ »ari^^ii»2f} ^ _iwf gested that aeuro-

smmeular moieimRed^ diMiMi«att.<m'eomi^^

.preliminarir ieuill',.d»ef 'Uf ^, yH|g pi |.|| ti |i^ pi* full ^ ,

dose of^ ,

mkmMamikm ml MikM dtfli 'MfcUt

39

Miniiiisw of m m

•oitreo of pottttoit»t 4 M«gp»o« itt 4 ) •

iiowovojr* auXIiviKi «t ml (1.988) hmwm Hoiinfl tiM
••If taoinQ fo lo iMffactlT* in jpcovaoMoo of tli« nox**

I£iS.B£.i£lilSljai *

Px«€«r«ri««ti©n im tli# moot «ff*«ti.wi iMa»ur#»

knoi#R to pxmrmnt •uxaiMithofiiw lii8oe«8 muimxmm mtimtm* 1%mi
tmm i« in^ilod mmmll 0@»ag« of • aoii*0»poJAxiaiEii

otiaclo jwiiaiiiott# i» •ffeiiiislotoroO prior to tbo iatajlMitioa
Oo»« of •oxnMtiioniwn* Vtm mitfioO hmm Imm intn»8oe«d bjf
nwl&mn (J8S4) i8Min pcm->txmmtmm% with •mtli doo« (40 lag)
of GaiioRlMi iKiGeooaiaXir r«<lae«<l th» iiici8«oe« of
from m% to 409(« lo«a wmh iowor Ooso (30 og) of Qmllmim
%m» l 3 «mi pror«4 to tt •ffoetioo in roOtieiag t)i« imiAmmn
from Sf» to 3t?( (Footor^ ifOO) • ,

8iok«rO« 8iirtlo« wo l*iiii«tiai (19€|) foima ©alliiiiao
mitmctWm oto® la mrnrn n£ 8 nf tlilli pro-trootnoat tAth
im 5 m§ MPmwtlioaitOR ito*lf'"lnsroa««0 tlio «r«10l«

49% to 7S%» liiii* aiigfoatliif m«t mmm aMOllor Aoo* #i
•oKMttioiiliiii iid#fi «««•• iMNil* iOMfo i^oliilly if it
giiNia lifofo tkiofoatoM* '
offio'«^ of •▼oaHii*«r' fS Mill uMim 'I^4l3l$jyi
IfioiOinoo tioro' «ootol|i«i"'ffiMi tOi’ uSmtlum

I 'i f, ^ -I

I^SI

40

iiici4«»e«t #f myalgia ramadiattS tm«ffi«tiHS i4.tli Vtm sloif
injaction af mxiMthDniiaji#

Marcia# Dtnrn (1997)# Ha^xhedmx (1959) toafa iPusH^i ,
d^tialtxMmrariiit aqiialiir aaafMl £»r aaiMi purpcMiaa laoMaacta
mt aqraigia waa rwliacatf fraii 9391 M% iiit)i 19ia pra^traatiaiixt
aaiiogf &*tabo»wemti.m tof laaailca-Kailaaa (19ii)«

Sinea Hian pra-traaitanist wltl) alM«it all mn»
9a|»laria8ra ha'va baan avaluatad to liava thia projpartj*
Maehaniaw of action of aoch pra-traatawint ia atill uaelaar*
waud (1998) haa jj^tulatafl that oecloaioa of a fraatioa of
raoaptor aitaa oeeiara hf aoa-9apolarisars landing tet
daval<^;»nMint of dapolariaaticm of ralaticalir laaa ffimini«iida«
ttm atippraaai<»i of tha miaela aetivitr oar oeenr hf

aoail doaa of aaii*^polariaara oahifig thao laaa aoaeaptibla
to tha attxaoatlKMiiiaR induoa dwiaga (colliar# 1978) •

apart fxoo tha oaafiil affioiMf# aaoh aoall daaaga
of non^dapolariaari haaa no aigiiifioMit elinieal aifaota
aiceapt mttwtxmnm of oooaaional diplopia in anaoaptihla eaoaa
icnllan# 1971) • . Yat ma naaaiira raoaiaad a eritictiao fro*
tino to tina# loatliicdala at al (1959) propoaad ^at too
thaoratioally antagoniota Ohoold not lia oaad aimnltaooootlr*
Madpi (1957) and'foaiMir 41999)" drao'ottantion to tha diffionl^
in roi^irotioii a90»diitoi'’^tiilil""oiio^ pro-troatmtot* Moraorart
liiia'ohii oatagoritod Wim iiiiiioiitioo' in proaaiitioii of
ofolgia-lir lvr'«<»9 idito' « 0 Y olia«raad

ioaignifioaiit difforthto;.;** imHmm of orolflo with 499 *9 sd
and n^mmt . ^

41

to 9*4 £rid«ac« of faiSo ia tw&tcli Itsiglit

and pmt totanie f«* 0 i.cnal.otiaKi woro abaaot* flioo mf
ptm»ihiXi.tf of dovoiofooat of dosoaaitlsation bioek noao

cuiloa (1971) tmvm coa^jparod Qtllmlm* €»tuboemmitm
and jpaneixjroniuoi rogairdliie ttiair affloatsT and atatiaro of
aolwitoiioiit aiaxainatliCMiiiw Mock* OallaiiiM ( 19*20) oaoi
found 1») iM moat offootiiro la jpcovidlj^ adiMiiiato kolaxafkioii
Init wit)i « Madorato dolor lo i^tiaot (llS ooe*} or AootoedJifi
of racooojcj |»oriod* Mofiioteo kolajioklon oaa olao obtidnod
wltk tim tmt olieb aioalfloaeisiy dolagrod oaiaot

00 aktolftiiA of tutitorlMia o«NaiKfod''-*t 422 ooc* lAioii oofaj^orod
'to ' it ''OfMonio of oonunoli'*' .. Jnooroxf • tiao kMolnod - '

42

hmmn ti> Im a feattax ahalata

ttian 4*«ul9«Nmsraiiiia (Tirtiia* 3lt7SI xa«airiliiif Hia InlitMtiaa
of faflwi«ttialdboe«i> inoMoiioo waa Immxmd tmm 32% to 21%
Mlaoyio (13 og) viieim glvao 30 aaeonAa paeLor to
auscoao'ltioiiiiin «k 3 it IweoM caiir 2% liian Qiliioiiiia (3MI Ofl

nmm iHiad @0 ORconda prior to auaeanatlioniwi* Fra-tx«atRMiot
idl^ 3 atg {¥> aaconda or 60 aaoonda prior) and 6 tig of
d»tel«etirariM (iO aaeooda prior) ramltad into iaeidaoca of
faaciouiatioo to ba 30% and id% raapaeti^alf *

aiiMO* UmmmK, d^tabocmrarioa aipiiiioMitlf afeioirtoiiodi #io
dmratioo of hlmU Mmm 40S*i3 aaeoada to 29i*3S aoooodo*

ocmalMti# ^mi^x and ««oifaon (1975) oooparad tlia
d-tulsocrorarina (3 i^) and paneuxonitw (S og) and' both
offieientlf reduead tha aevara f aaeiculation and ofaigia*
d»tubaciiraciiMi waa aoparior aa it radooad faaeioaiaticma
fxo» i00% to B%, whiM^a waa much iooar t^an ineidaaca of 46%
in PanourcmiiaR group* savor# faaoieuiation and i^algia war#
aboiiiOiad froo i0% and of tha patiaata roapaetivaiir*
oaaat of paralfoiac iatatoation ooaditipa and iaeidaaeo of
•at iatuMtioa «oii#iiBg oara aiptifioaatly almiiar oitli

Hia pMiotiroaiiw was found to bava aora proaomood
•ffaet ia prooaatioa of faoioaiatioa ratiiar iliaa af aigia
Ctxodalf# »fo«*aitMi aai toiiiolo# if7f>« it l«atarad faodi*
inlaticai $mm tl% to 13 % and analgia iron 3»% to a@%#
itoto^ovor*, wprorilr of poin rofuiiaad ua^aatad* Hoiarato
offi«^>i tHlo lip;|o«o o^irptd iWRa «t ai m

and Jansnn (1979) oh»«tm6 miiicBcty

of poiieiironiiiiR «• it rodveod fnseieulatiofi oowit fmm
Zllm% i»> %T m%, ttucb iowor tti*n th« faoeicu lotion comt of
SO *5 in anliwlnn gxoup*

^onouioiiiw woe aftioimd to )mi iMtat offootiiro vtioB
oonparod witli Gftllnf«iiio« dotubocruroirino «id Motaeurino
(Caaay Btltt and Cmxlmn, 1981) • All djru^a prodiicod adaquata
rtlaxatiofi, without altarinq tha onaet and duration of block#

Agoatem at al 41980) sapor tad iraeuxoaiitm pra-
tsaatawBiit to toa quita affaetiva «^ila issuka at al 41983)
atodiad affaota of Aiousoniw to Isa aatiafactoi^*

©annatta and iOialil 419 81) ha¥a eonparad tha
afficacy of tuboourarina 4 2 *8 Rig and 5 ag) # Oallaaina 410 atg
and 20 mg) » Pancuxoniitm 40 *8 mg and 1 mg) and Fasadlnium
47.S mg and IS mg). Oallarniwi affactiaaly raducad tha
incidanca of igralgia on 2at poat-oparatiaa day from $m to
33^ with ttia dtoaa 10 mg and to SOjt with tha doaa of 2© mg,

whila d-teboouxasiiM 4S mg) and Pancuronium 41 mg) also
aignificantly mitigatad analgia t© immm 29% and 2834
raapaotiwalyt. Paaadlniwm awam in doaaa of IS mg ramaiaad
ralatiiraly inaffactiwa aa myalgiaa wara olwaraad in 4Sifi mid
22 % «aaaa on: firrat ^ani mmm paat*o|»a»atlira hotaowar#

mosa ttMa m% aaaaa intubation mm §mm'r

fi»adiniiai

b«ittii««n 19 •» diccept 2S% i» pwcuiPoraiuBi group yiiilt pjm-
tmmiamnt witti c^iasiiac, tulx>eur«jriii«» ma^

ymmksonXvmt 2 miimt* pri«r to promiattia

incidonc* of 30* 30, 23 «o<l 13*$I4 roopootiiroli^ • ‘30i«

difforonco woo not aigniflcnat amcHag tl%« roouito of difforont
pro-troatMiat gxoujpo* dmmwmx, tiio froquaney of padn won
•ignificintly rodtnsod to S%, iS% m6 30% oftor pro-treotmint

f’lMo&tom ot ttiitadf oiaA ' tMi t |i O .<N i*fc tlm ^nwifc ia . tia lalonin

stolw ilP tPit* still, m . Wim$ tikof mt on o laiiiMraen

ir«vent tii# ionic flwx at tiw tirae o:

digitaiisad and tlia tratunatisad patianta* to mow turn rlaa
in piaana potaa^wn conctatration to teooiNi aPboiit $0% iaaa
thmn that oocnrirad in non^-piraourariaad patianta Cifaintrant
at aif itdH) • Ilka potaaaiWR coneantratioiia tiajr ta xradncad
aaan mail ,teil«w t^an tlia pca-imlncticai aaiima and naiiai fali

'Wf ■“

iiaa baa® rapswtad to rawain batniNtaB &*%& m mlA> Cbaii#
DoiMlaa# If 741 and Q#a7 m ml/h (HaJiaiaiii at alf, If 7f) • ^

Kontliifax-i at ai ilfiv|"tiaa obtainad potaaaiiiii
mmmtmtim to atiow a oajiiaiwii fall ©f•0*»l m ml/u altti
ma p«n»w»biiia il.

laaali iwaxa faiNicoi ^

4e

IcSa m m&l/L (at 2 fiiiiiititcal « 3*i<l (at 3 Sautes)# 3*@8
(«t S Riamtas), Itif (at 19 udautaa) 3«7Q k msil/h
i at 29 miiitttaa) • .

Fama« Mirakhiar, Chaig mm ainjj^atarad

tiia Qiiiiiiittt# Ftnciitaaliii# g*tubtKwrailaa aac«imiiiMi
ailtiair at t or 2 idxiata prior to tba iaJaellMi of miaa-
mattioniom. Erarf ragiM# l^ut pMaoiiroaiijia (1 iiiaata groap)
attceaadla^ ia ra^aeiag tita li^fporkalaaicr raapoaea* ^Jal lamina
it mltmtm graup) moat affaetivaJlF rwlucad tiia potaiaium
iavaia from 4*98 a mol/L to (at i aiatita) « 3*1^ (at

4 Mdoataa) and 3*fS » mol/L (at 19 minataa} « tba ooaparabla
potaasiniR iatala in otHar grotipa vara aa tollowa •

Piniii

m ^sfifeUfe.

indwction *

4 mt«

19 Bit*

CSaUamitia

(2 mi*}

3*98

3*^

3*88

3*88

!

1

§

(1 Bit*)

4*18

4»ii

4*li

4.28

PancuranitM

(2 «t»l

3*98

3*83

3*81

1*78

TutecHtrariiMd at4

3*89

H A'Itt

3««S

3* 88

fi»jbii«arafiiiMi(l mt*)

3*89

8*99

3«i9

3*S9

¥a«iiioiiiiHi

(1 IBital

4*23

3*98

% Ad

4l«i wm

3*98

iNMemonitaa

(2 ait«l

1«93

3*ftl

3m§§

3*89

(AH

aalaaa in m

‘i: . " .:'r4

i,'.. 1 . ; ;

I'..,,- ■ '

attHiaim at al (198# alaa teata anown a aignifioimt
ratfiMitioa mmcmtgmiim imm 4*9* (pra*iiiili»etiaiil

fasoieuittHiaa* iMijr« •••n oitlf in 3^11 «•••• in lliis gmup
thiiy W9zm ia jl^tiaata «ft«r «il.f taming

»uje«Mitii 0 adiaii 10 iig* SiwilaiiriF# iaci^^nica af inspalgia
if«r« 44% mi& 9i% ia tlia raapteti'ra gaouipa# hmtmrtix, maicsalajt
aaiaicatioa aaO iatii;attti 0 a «x>a0iti€ma umita far fzaa

•atiafac tori' altar pta^traatMit idta Oaiimiaa ar oaaat
waa Oalara^ fnoa Ovff Miaiitaa to l«04 aiiatitas «aa Onratioa
of toiooli. akiortiMMii Mwm f #4 wlaixtaa to 9*21 liiaataa*

y jL% tfUli

IIBPlfwiwiflp: ^^PIPPlPWP^ ■'Hr •’KP toto tRPW* tpp IRIff ■

^ .i^. juriiir-. y||i iAfi(iii[fii(>ifaiitki J| d|h jiiijik m j^K iiiiiiyjlldiiijatok.,^^ Jl A itlib stkAtjau Jm j^, iiMiaKia lillfri ■ tr^i ttMib jatatu A

mt MX'iMWOTMI&lill ^ AH

.4ttM^. t-attiii. .^, ,yAMw. fW'ii lilltwjll Jji jjK fMi ajMIullil AHfe tilib.^lto>4teii[bFliihldi^ iu iMMifeA Hi jagb HI ' mtte JL litilltfii I'lliitjtli fiilr- liflihil ■^‘ff|ti>4H#|' Ik |P%

mmmmm iW’IBIw mimmm AH Mmw VIMi WH

'.•I

Hit* fMMi'MMi mmn ii% wmf

mum •» 9 m m/B mi latll

iff«t Bmm #i 40 nt ci«ii«[iiii« wm •ufusttai

49

fey (19S4) » . tut tlii coii*«ii*ai i» in immsai #f

inteiriMdintn of 80 i 960 ) Imcoinio iwgoir

0080 Mlv«rnoIy ifftct tm# I’UJcaiMfthcmitin block (Millor A
1971) Jovtlng to jpoox xrolnxifig aioklng intubutloa
difficult (Moioiy ot «l« I 9 il)»

ionnilHi ond koilson (1964) auggootod do««8 of
i^tubociiirairifio to bo administvrod on ho<i^ waigltfe b£»i8*

alcmoniiw (0*03 ng/bg)

fioiitiotto «8d kbalil (1991) argiaod that waU potfoaod

vijM istorval totifocn |tra«%iraatitMmt and trnMmmmmUm
to© miMiiiMKI vaiialilo batwoon 8® aaoonda (ttswacal ot al# lilWl
to 4 (iSwilMi ot ol# l»if)4 I odawto intwroid

tColliiSf 19?S) -itiai 3 niinut* iirtarril Kftfclil# tt*3

MBd 'Fmxrmm mt ml$ liSS) if«z^ alto r#c»iMiMiist*<l fttt 3 iniawt**
raaiaiati m»t tctttjptiblo tx> oMeiii miJdiRwi^ offi^aef
of toeh ]»r«»tiro«l»i»nt (7«klei •% tl« if72t atillojr

MATmJJkl, Am METiMMiM

Tm •«!«% wm mMmfd in vm B«|MirinMifit

®f lo M.jU*B, c&nmgm, ,

with tSm «iii to ohownr* Wim of th« aoH tmlm> «•

w«ll m lawi p3D*cmrojri«otion# oror th« •uxwMtli'oiiiim i»<Siic««l
foocioilatioiio# ii^aigia md hyp»riial«Ria . . Tt» officacy of
tooth ttoo iMiasutoo woo «i«o «irai«*toi in fiio ;pf»w««it4oii of
ttioso i^oroo otfooto of »yxMwldto»lw«. Tiw pirocorarliation
wan poxrfoxiMft oltliojr idtii <lai3.«niiMi ot with Paocutoiiiim^ ao
of foots of tooth thoiHi dtii^o woro oRoifiiod to eoi^ro with
thoso ©f Soil Voniog*

Sifhty inioot potLooto of oithor tojc tootwoon 12 to
if irooro oemprioi^ tho mtorioi for ttoo sttafiy • All lotionto
tHMSongomi tmotai oBoosthooia ioir wmti&m typos of stargioiA
pcocttdwroSf Iji whieh sMtowJUttioo is post-opsirotiwo psriod was
pvoiliotfltoio withio 24 hours* agoh solootloii was iiiii«rt«nt
§m toattor atoloarstaRdifig of soicaiMithoaiitii initioai agfaifia
as thaiy aro hoowi to tot mmmm amlmg liirst poat«oparatiwo

UtoiPioaaiy# tha oaaas of aajor aMoiatMii or t h op iWH lIi f>

saryioal psooa^iitwa wars aaaiiiala^ fiosi ttia stiaty* iiaiiasiir*

jiyiwttcJllit " wlriiiSiSiiiiikL ' iiiiil'iiiM' tfiii liMlii BiiWifiiii imp iM atoav -Mk. liliitr itfit w ' twiiii iiiwii-i itjirfin' '

pillEi9il1pA Im# Mtoillii^ Ml Xmm mKII>mmmw9 ^

iMiifii# iMiwiJyiyp

InditactioR of md iuiir<»tiii

wmm not «• «li«r liight altox «li* iacidonc* mA

of

VontpMetoro woo pox-ioxiiMid •oiiitiool.lif imS
&mmm§i9 i» lyK woo AtmttmA* Curo woo tilioo »«% to Aafnoo
on&ir oAootDolfto oontoioiiig ooA^ion oo iilflit oiioot

tlio tloM potoooiHoi oonooBtrotiono* fvmmfgmmnm w&tii
%Am Oj woo iuftlotoi itooiit «iroo otfniitoo pfior to tl»o
imrnmUm of piooottiooto* UaOmUm ®f moo^woio woo
purfkuniioi witH mo onAwkion of XoJ. fHAojwitooo S o«A|
oqI imwmm9mlf olonrity tin oiolltioo of ofo loifc

rttspiridicii w miiii%«lfi«4 till
ooiii|^l«tioii of tiio aorgieol pxoeoaiuro.

mm ittiiitaiBoil wltli Urn «f

Oj ♦ M^O «' TmmX g«« flow »mim woo otfjwotod to

aroamin feotwom litaroo/oimato* tlio arotlo of tlio
tmi tiwi oitxovui ojclfo woo Iwift to zroiwiiD IS t §7*

BooiHoa poramtoirot otij^iotoi for tho prooont
otoSyt ooeh potiont woo eoitotofitly oooitoiriwl to oooooo tlM
witol fane ti OB iBel.iy»iiiig poloo* Blood tfxmtutmm and

: fooeioolotioBO wojpo ©boorirod of tor odtoiBiotrotio® ■
of ouxaimtliOBiin to oooooo tiioir owtont oed intoitoitr*

1%wy woro oo foliowo t '

0 I wlsiMo foooimilotioiio*

o t 'fmtf flAo fooiol Kiaoolo ooil fiogor tlpo

OOMPOHIBitO*

t lUttiMa eoatrootioBo &i m& txmk m& Hm

iiiiam lifliiiiii'-ifcii iiiitr ulUh'ii ilBtiiil'Illl -fifeiiuJI jiflMtak JtUlt-

ooo Vifoiim ooBtrootioao of tgimk mA tlio

liiiif ■‘iBitiiiifiYAiiti itiiMi-iliilir’HiiBWif nJ^ 'dIfaoA Jlilk. ftilki

iPiwtiK&wyi#* .. . .

«lio M^twio Of liy|iorl»J«iii© roi®>®»io to Bwwt-
Mttioiiiwii WOO rnmmtmmA br tl» ootiiMitioa irf mmm jpotoaoliiii
boforo oiii oftor ^tbo ofteliiiotr^oa of Hi© . Thro*
lilooi ooBfiSoB mmrn'Akmmiwem m Bopiroto ww*op«BOtiiro tlto

, ,1 ;,l ....'.i'.i ' -k.,.- ■. , . '

vilili warn Iwl.t #1 H.ff mtoolotoi

mmwm Aiy vi*!* mmmwm

'Tim tpteiiitii aeluAicHoi i» .-iptftivd • iim w^Bt,
into « ii®ii«'li»KLm»«K t%mm whifih immm <»oiow«<l

f vt itfi «Hf fMMmtt mm wllii li •• ai @i

mBUllmd'mim m m$lm Wm tail© of I • IW*

»sm€imn wm csas^irai «lth aolmtioiui of jiotoooiw#

libiofiSot ifiioii w«ro m<&m S^r iiiixtisigi tlio itock
•toniard (10 m •ol/l* • 0*746 of Ojry J^taoitlMM ciiloyi^aoA) •
71aiM phofoMotor woo owitclMO oa mA PotaniiiM flltor warn
iiis«rto4* 4ir jproasuro woo odjuatoO to 10-I6 9sa&

pas oaippif woo ifaitoi Id obtola olo«r HaiM nittioiife mj
» 0 ot* Svib«0(|u«atly# tlio v«rio«» ottadazdi tpoli^loiui troro
placed in lorolled boaiutre* Initially, high potaoaioia
•tandaxtS (0*00 mS^L} wm» aprayod md noodlo was adjnatod
to ttm mxrk of 100* Soxro aottljag was #io#iad with doublo
diatillad watatr* stmh otindaxtl was aprayed in tern Id
CDnfixm th« avan ipraad of tha aaading oraxr tha seal#*

Thm dilntad apaaimn aonpio waa apraad mad raading waa
aatad# it waa ianadiataly follawad lay apr«^iag tha two
naaraat atandafd loiiitiona idiieli gawa raadinga Jiaat lii#iat
and lowat tiiaii lualmiawii aanpla* 4ftar aacH fa«!i»g« dbtalila
iiatiliad watwr waa aprayad to eDafixti liia aaro aatting mM
to n»la out mf arxitt dot to jranaining potaaAim*

AaaaaMMAt of aiiata’Hayalgla waa #»iia Iqr wiaitiag
tha aaoh fatiiaitt aftac 34 hoiira of aorgafy* initially*
m>m iioji«>apa«ifle angaicy waa a»da xagatdifif tha poat*
o£«iratiwa atatwa of patlant* «i0ian patiant eowplainad litoiit
thair aoliaa and paina« tha aitaa and aaaarity of paina waira
taeordad* In tha oaaaa of nagatiwo eoi^plainta# tha ipadiio
fwiaxy waa aaia to aaoartain tha ocemrraiaoa of Mtola paina
atiffaaaa* ■ /V' "

"Tb® jpaiBii In tb® vlciiilty of

»arf«»y •»<! ijij«etlon w«r« not OQm§>Mmxm& m •wato*

IMidM* hom^ fe««lc®elMr in camm #io mS^rgom Iltbotoiigf'
jpooitien wm mim not iiicl.od«d in e«t«$oxf' of

mkm ^ . .

tim intonsitur oi pain wm gr«4«d aa umar t

£1 I Mo fRoaeia padn*

ti I Mild 9 «iMi:ailsa<S or iocalisad pain*

♦3 I Pida at awnaroos aitaa/aavara pain at a
alftfla aita«

a3 I Jaaara pain at maMrona aitaa*

Tlia oliaarvatioiia, niada dtiriap tha a£»ip« wara
arrangad in taJaalatad fora to ol»t4y.a tha inoidmemm and
Hi# ,1, ^ Mii

tba poat'Hsiparatiaa a^raigia# aa par tliair intanaitiaa in
aaah of tba ffn»mpa* tba aatiMitad plaMia oonaaRtrationa

tWl# ^ ## upf

aalaaa i ± ataniari daviation I aa to find oat anp aluHtgaa#

If iSi|P #aa» % # % Hi#

S ||4ll'lt%IMI ttffP !KjiSIIK%#4l IhIMI Iff

. .. ...it;?'.

58

i* *t* t«»t for thii proportional* valuta i- l?o cowptro ■
ttio inoMiMoa of th« faaeioolatlona* m» voH a» thm
oaralQlAa* in botwoon mm pntioiita of tiMi eontaol ftoup
an4 oaA of tho pro-troat«Mnt grmp*

vihmxm

Jrj ^ Fg

% ** I'' ' 'r' " It #

^ DO ( 1

' H| Hj'

dmgxmm mi frooioii • | in^ ♦ n|l • 2 i

• •••••** (ll

**1

Ho* mi.gmtimtm wi,m
immimmlmti&mm or a^aif ia

'bcital niaibor of patiwata ^

(in the oontiol »

Mo* of patittRta wim
immimlmtSmm or a^alfia

natal &«t«l>ar of patianta

Un pro^traatniaat ffmtp)

fij •• Total oiotbar of patianta in pra-traatiaKit

p- (a •!! ♦ p« Ci^*D , '

i»l ♦ aj|> • 2 ■

« • (1 - p)

2* Fairait ‘t* taat •• analpaa tn* pat tarn mi mm mkmm
in •§«* pIMwaai potaaiinai aoaoaatratian# tn iwlivil^l
-ffonpa#, fan* tbaUr laa-lnioitlon aalnaa* ■ ;

i •

(Sr '

m

. j;

•igpif !««««• ®f tlMi iltff •!»»«• ia tawi faiwa •» l»* twi«3f'
MatiaiMd

i XaalffaitiaiAt

» m @»@i • aifaifiaaat-

# • £. i#«l I «A#ilF aiinAficait

60

OiaSRmTlQtlS

X

Qm^

sx

C2s9^

XXX

Qmmjf

xt

mm I

m*jm

iim

IT

X «Ml XX*

TIMi mgm of jpotiMits wm xmgima fjroit Xt to
md 0SI6 of Itio potionto'ifojro of tlio ago hatwtm 11 to
fotiro*

(^1

‘iim amaber af th« fnaai* jpat4«iat» *>wlnat«d in tlit*
of prmmt atxidit tii# fcoportion of nialo and
final* p*tl*fit« «•• foiaad to b* 4t t S8 { I i i*3S i *
coliicia*Bt*lly mm ratio *** i i i in gmup !¥•

Titei*. ^

<iroKi«

■

iio*of

Al*,.. ,

Final*

Mo.

%

Horn

%

i

a@

f

4m

u

11

ai

:S

4m

49%

III

20

■'t

tin

■ ii

m%

XV

ti

m

It

mn

i#iim

*0

WfW

u

42M

4«

m%

worn mmuegmmn of tNt rlaitol* f aooliMlatiiMMi **«
&bnmwmA mmm aft*r mn aciilnUitraitioa of mm smmmtMmmiwm*
fH* 9*tl«a«o i» til* oontrol fsotip nor* o]b**rr *4 to mimm
liiflioot icotiMMir »i a* •adi jpatlaat im mi»

9mm ll Hod imrnimUtimm of tn* vaariaig iiit«n*l«|r*

ftm' aHMt oioioitito Mii mmmm our* mmm $»

fi, at MMi a#« of .«to piit*«to f«av*«tio*ir*

4Sif£«r(mtt £mm tilt mntml

Vtm fiiaeieulaitioiui count* were greatly lowered wheo
flitaaore of self taiBiiig wee neploi'tiNi* Oiil:if 2S^ of tlie petiente
in eeif twRing gioup (©xotip X2} Hiowed feeciculetioae end
thoee too were of tlie nild inteneitf • Howiwer* ni34
feeciculetiono were eleo olwierwed in Idle 20% patient* efter
ttie eelf tenii^ doee (Id eg*} «£ tlM ameaearttaeiiiii*

Poee* of

m.

6‘3

Th« of j^xmenxaxizmtion wait aiao lauRO

to b« auccaaaful in attanwatiaf tlt« faacicuilatio®*.
ynif 20 % oas«s in t^alianino gtoop (airoup iil) BhowmA tJ»«
f«»c4culatloii»* %mmK9 iaaciewlatlons wax* abolititiad md
fragoaney of nsild m€ »odar«t« faiMsieulationa wara 15 «ti4
5 ‘/« raapactivaly*

51tia pwmironiuai pra-traatmant Mdarataly raducad

«hay waxa aaan is ana of tha total 30 aaaaa* Tha aild loid
nodarata faacietilatioa wara viaibla la and il& pata«r>-&a
xaa{»adtiaaly*

lifeit, .1

■mM.

Qmvm^

Thtt post'^IHiirativii mf'alfia irar* quit* ommma in tlin
p«ti«nt« of tlia mmtx&l -3^ $%% p«ti«nt» in this

giroup conpiainnd about tl)« nnsaiiajr pains asMi •tiffnnsn
in tlin rngion of tb« book of nook# Ian* ikoiiSiter% iowor
oiiost erngm* pnotoraJUi nnfi oppoi' iMoatinai wtHl* ttw nfaifin
fwaainoi ioO'Siiis^ m « siaflo Mto in 2fk mtioatn it
wan of iniiS intaonitr* Tha isodarata ani anaata paina vara
piraaant in SO «ai IS% jpatitota raapaativalf* Tlnyui# tha
fraqnanosf of woOafata n^alfia van fooiO to tia kiOhaat aa
mar in of tna patianta mo liai oonpiaiiiaO

of tlm ' attar paina •

.. '■ ’ma..pi*i«itn«^i» 'fUa centmi fronp# waia mim atmlial
ta"'aliit«rva tHa oorraiatioiimip intiiaaii ma oaaiiffanoa of tkO'
naraif^ ani ma ofO' mO of pniiani-a# flni tanitnof „ : :

««• oimT994 to tmmin klglicat

piitiiWi'l:# h. i tyit i9 f 99# HlJPti SG iViUTA'

g««iti|Ni Ho* #f

06

to hmm w** otai«risr®d to

comaiii higli«r In th# ftmmlm iwtiiiiitn* 72% Qf tiin fmmlm
|Niti«Rt» in tilt control gionp conplnintd to hn-r® tiwi
•Ittr-pnin®, i^iil® tiaoh pnin® «®r® pr«t«it only in %%%
of th« Mftl® p«li«nt» in th® aami fioi^» il©iiio®«r# th®
ftWAlt® w«r« w>r« pron® to mftmt nitli th® Bmvtm pains •

. a

wK mwmAQAm JLE rvlUmlOil m miKi Ilf mlli JpllJllisiM

iB,.s2aiiaL-aiaM»

s«x

lotil

Mo* of

"Pr®iohoo «f

..:«ap®Igio

llyaifi® groiS®®

.

,:: M®„*

%

”T'

jLaife ”

M®I®

f

i

iiM

1

I

t

y««i®i«

: il

8

72%

i

4

,■ ...t . ■:■ ■’

a

Total

m

18

iS%

4

f

8 .. ‘

nm »®ti®nt®, in th® ooi^rol «r©wp# if®r® ol»®®rr®«
to ®®«ifcii out tny fowinttel# ocMr*®i®tioBJ(diip imtii®®® th®

OM «|M mraiat*. iwt mw 9tmwrmu>m *•*!•«
a» ,ir***«i *h*,wi»*i«**>*> >

.iOlWINm, IllM.* ^ -'■= A- -

: ^ ^

I '4.: i’rt-sii&isifilftsi!

rmiDtd in 27 %,

It', : ; .

MflS ■

*

m%

s

I

%m

1

: m%

-rfe .V+'A**,'?* f i ''

<k”. *

, i *,Aik'

i#ii

■

■ ;

co»ti»i graujfi. occit^rntaett fi»f ummzm f«l»

wa» ©b««rvi!«S ia I5i% in ibntb tlMi

ftii't*!. Min*

■■ ylMki-iJIm ' 'IttliLMHIie 4il^ iJI

911

Hyi^lilittrjMik V' 'ttilii 'illlrftW' 1.1^ ■lililvi

v4 f'' I “ vU 9 '

: ^

ji§siifii^iiisfil^

Thm mxmmtM&miwm in i

mntml §mup^ iaiWB«l • «id •inaif

tUin £i»«ixMidi sigaifiewit mu nptn

th« 10 iilattt#* 4ii»«nr«l altar aaiioiatr^oa ©f th©
©ijuc«iwtli©eiiMi« ^© MMi wmimm si»m ©f 0»12 m ml/h ««•
obsarTinai idtti #i# rattf© ®f, ®*0i » tmt/h to 0*ii • rnnl/hm

Wlnmm f©ta»«la» ©©nt^tratliOiMi tl) itr©-4«iwfttioR •

m At 1 rnitMm ill" '-At 10 liiatt©© • Kj.

Til* potMiciipi liiowii th« tMidflner to xmtwm

t<»w*ra» VnIiMi «* to* iA««nral ef JLd niitiiit**

tilwik til* Mt«n jil*iM mmmtxrniQm lw«*ii* 3«t@

« ml/h f*t it *tlW #to«i»*« ®*11 m ml/h !••* tUMi to*t
0f pr**iiiati«ttiMi il*il Iiitol/y*

Moan toatat* toaetotrati** at S ■M.ant**

CKj - and *1 1» uimMim • *!*•

*§«!»

••.la (X

TrlTm

' 0*»i

§•00

••li

9*a4

0.Si

0*10

0*93

0*00

0«I0

0*3#

0*10

0*34

Group I
Group II
Group III
Group IV

!*•*«*♦•*

Age dtftrlbution

with th« iraiif* of 9*24 to 9*10 m ml/h

overall ooMpiriaon of ml£ tiwliig and thm
pr«cttjr«acl*atloii •howod that ht>th tha maawcas wmm aqually
®f foctiva iB tha amppraaiioB ©f auxa»£aacioiilatiofiii aod th©
aoxa hfj^tkaiamia* Moi^ praourail satlOB* aithar Mlth
aailwiaa or witii FaBeturonitm aXa© aiaeoaadad i© tha

pxmwmtion of aiijea-af-algia to raduea tha itKiidaoca fxont
SS% to 303>i with Qal lamina wid 2S% witli imaatoBiwiii. Saif
twlii 9 waa not fhimd to ba affaotiwa in thia ra^ard aa tha
ineidafiea of i^faigia was InalQBificaRtlj tadissad to jramain 001I*

thm inqpit* of luiirifig pxoiwrty te»

providtt mmmllmait memmlmt intiAxation# li«a xr«o«ivoil a
oritidni fxofR tiai* %o tijpi for its potoatislity to laMtoeo
ttis f asciculstioos# tti« hypsrksisnis and ths s^sigis* t2i«
initial, two of thutiR mxm knowo to oeoor Issnodiatoly sftsr
tlis us* of tli« dirug» idiii« tli« ayaigis c«i trouble ths
l»sti«i)t m'^ou days af tar surgary during ttis iats post*
opsratiira poriod •

A aiHMjnius att4HBpts bas l»t«n »ai« to ndnisiiaio
stssii aStorso offsets of tlio smAOMtlioiii'M* iliooo loiasuroo
incltidod tlio eliangos in sait of mm izug# eliango in indo of
odtainiotration tim suxsMitnoiiioii* I'ro^trootMiit witn a
niMiMir of drofo ooeli •• nyiooafn* i»antxoioiMi# i;^sopa»#
MapyLoiMi miipnato* oaieiinR giueonato and oitanin c aiao
hmm IsooB owaluatod with irari«d>la sueeaas. Rocsntiy Lysina
aeatyl aalicsyiato has baan suggastad to prawant tha su3ca*
paina (Magnib at ai* I98t) •

nm pra-traatsMBt with mm&ll doaa of anxMathoniiKai
itaaif Ciaif Taaing^ and that of iioii*diqS»oXa rising ssiseia
raiaxiflita ipraomrazisatiott aitii tlw Qailaatina and tlia
JPanaweiiiaiii) haa imm attaaptad in mm praaant study to
anralnata liiair affieaey.-

Hw tiM icit«rr«J. ^twmm ti»t pwmmrmximiskl&m md

•iiRiiiiii(tX'atio» af tha jp^xMitlioaiiaR tia* Iwjp* to to

i «« tola ae^auto Ima toaa xmwmimd aaaoclataa

witlk tto iMxiinm affiaaay of tHa aMtHod (Miliar^ May^ 1.9711
aiQ* iaii# 1979 aito Maaay «t ai« I9 i3> «

tlia practtraxiaatlon toa toaa rapwtad to rMMin

aoa«a of iioi}«<i«|>oX4i£laara to to aaMlniatared for toa purpoaa
of tli« |»r«cora*l.aatlo»» In owr atody# atafidard dbaa rogiwa#
ratoar toao tody aaifto toaia# ha a toan waployad* Qallaniiia
was adnioiatarad ia tha iotamadiata doaa of 29 m* ahioh ia
alao aiifgaatad hy foatar (1969}, Baoaatta# iOtalil 11961) iMd
Stallivaa Cliti). i^mcumniwm waa aaad in toa doaaga of 1 ng#
ahtoh la raportad to to affaotiaa withoat alt«ria@ ttoi
aiucaaatlioikiiai Umit («lltt at al, 19 ill •

Tim faacicuiatioiui uro transient u^^coordinatad
Kisaelat ma^mmntm TImy coincid® to th« initial d«polairi>4tipn
of tim niuieJLo fiteros and iNirhapa oeowr •« « xmmilt of pra-
jiaoetlonai KvcmptQS atiMmlation hy th« •uai«Mitho»ito&

(Kitwaura at alt 19Si)«

Ciiil«a C&971)t iDuttm at ai (2977>i. liitt at ai

Tiw j^aa«at atoidjf aiiowa tint tiia iacidanca of tha
faattieolatioa ia ^oita toLgh i» tlia patiaata of tlia ooatsol.
gcoop* of tlia fotiaat la tiiia gxotp Ind faacioiiiatiofi*

Tin iataaaitr taziad ia iadiTidoal pitlanta md SS# 3S and
lilt a# tiia pitiaata iui'aa i^oaa adid# nodarata aad aaraza
laaoianlatiiMia taamotivalir*

xmmt C20'^ of th« patioiits* «% Hi (]9@7> atioo h«ir«

olMi«r9«4 f«jiolMiXfttions in mm.dk of tlw «n4

Imsldmmm of niJUi# ooiox'ato nod ooiroio £«oolotxl.«tioe
l»» iMi %%0 20 mad 21% roopootiooif*

kxumx et ml (19 331 boiro obi»erir«d tho incidoQco of
faocicu lotion to bo $i%* ilowoiror# no jpotiont in tlioir
oorios aihow«4 nororo foocionlotions ond mlM «n4 oodoroto
fosoiaulotiono woxo jprosont in 1&% and 20'^ potiontn
aronpoetivoly*

Tioi (refwtion of foocioulation in ioportarit on
thoiir occiurrioco in abdoiniiMl wmcIo my piovolso m tins in
iiitir«- 9 «»tJrio pr •••«■• and oubiw^wont rogurgitation of
gantric contont* (Aodorooa# 1962 1 ^yliOf 1963 1 l*a Cowr# ©•
i9ifi and MiUnr, Way 1971). Tima tbo risk to aapitato aiaoli
aogorgitant oatorial ia tiacraaaod mmy fold particularly in
pationta having full atooach and dalayad gaatric oiptyini,
aucti aa olcaitotri« caaoa and tho fatiaata of iatoatinal
olMPtmetioa me having aouto trauaa*

Siailarly# tho f aaciculation of tho oatra-ocwlar
inaioloa lay «oatrife»Kito to tho riao in latra-w»cular pro aaur a
Mliieh asar ha dongoroua in caaoa &i porforatod oya Injury md
im patloata of Qlmwemm liiiUar, way* 1971# Mayor at al# IfiiK

Initially faaoieulatioiia has alao booii r^atod to
4ito a«ata*pii»o ioaviilooa# lfS4f ioi»ilco lolloio, liM) i»4 '

aiailOM)iy|N|Xl^^ iMlUPF a^ 1914# iali# atof^oo# IftH#

Ibut »o aucli r«l«tlOBahlp could bt •stabliahtd bf Morris «
mjom ClfS7), JU««t}i«rdal« at al iurtlas Tons tall

Ci961) and mta (19 62).

'IfeMi obaarratloM #f our •tudi' ooufisaMid th« mplmlm
that tkM oceurr«»c« of thu post •uxaiMtfeoAl.iai .paiiui hmm m
«^rr«latioiia)iip idia Ineidanca and th« iutansitjf of Idia

viadblo f aacieulattona.

#«11 tho jpatioota in ti%« oootxol ox^up of praaaot
sttadff atioifod fascieulatioo to Tsm ’riaiblo but enlsf 6S% of
l^oin danrolojpad ouaco^paiiia in 1±st« la to pCMt'-oporativo fiourii*
Ttm soiroro poitio oceurrod in only 25)£ of tOo patloiito who
showod aororo faoeieulatioiis whilo thtojf woro aloo •••a ia
tho tf% of patioato who liod oalf laiiiimikl foocieulotloii*
Moroooor# tho njralQia wa» not coaplalnod lay S0% of tlio
patlonto# in «^ic)i oeworo faocieulatiooa woro soon*

Mownoa ioudon (1966) ttawo liiowa ow^ tHo abooneo of
tho agrolfio in lUo potionto in which ooworo faooicwlatioao
woro ooon whilo tho lucid «©o of oyalgta woo aoro thon S5)4
onong tho potionto* ih-owing only odniaal foawiculotioiio#

I Coiiior (lf7S>* ICofoo ot ol (197'7)i aonnott* xholil C 19 til*

' Forcoo (I»d3) mA Oillani ot ai (2t®l) supp^rtod tho wiow

’ Mint inciionoo oad intonsity of tho faooioulatioa howo no

? of foot oooir tho oo«urros«o of a^yoigia*

f fho alMMineo of this rolationahip hao aloo boon

; atxoatthoaod hr ^ ohoonratiooa in mi doit Taniiiff giouf of

but l±i« occur faiK;# of th« •iix««piiKia rowaifiod wnoffiMStod.

Th« prmmat Btady pmvm* tbo officacy of th« ii«lf
tmisui tbc j^r«eur«risiMoB in th« pmTmtinin of cuxb*
t&mimAlmtl&m m. '

dolo of oulCdMMtItoniins*

» '

ClS>li> isHm littv« offoctlir^jty ottoomtod tbo i»&xo*i««NSioo|yftttiiii

wi'^ Wm mmMmm of ooJlf twlti®*

Xbo jprociucftfiaotioa witti tlio 146) m&0

iK

filmilar fiiidiaga wore obi«rv«d by i«r«k« it^Ti)
who has oucoodod# .with tho iwoourfi'of ^If Toniisgf in
x«diaein@ the incidence «nd inteneity of f eecicuietion fxoii
100% to asl>%« Coincident eiiy« mild feecieulatic^ were
present in similer mmher of patients C20:4 efter the Xst
dose iiO ng*) of soxeea thonioni* Vermsi. Mm%, et el
hswe shown the reduction in the inoidMce of fescicialetioit

• Tim £iytciicii!liitiofi« i»«r« gxvutiy
to im ic 20% pfttiiHita* Tim

c«i].«tioift» Qi t3m isiM and Bo4«i:«t« iataiaaitf if«r« praaant
in IS mO iX patlant* r®»p«etiir«if, no patii^eit

a«ir«r« f aaoiouiatioBa*

m-m.

of f 4 UiGiciii«tion 130 iroMia 90

CalJLon i 19 til has pcoirad th« efficacy of GalleoiiM
and panouxoniwi «od d-tmteociuraxrim in ti^e inhilsdtioa of
«ii3Ctt*faaeicitiatione» Galiamine (20 mg* 3 minutee prior to
the euiccMrtihoniiuB - I ng/lfig*) wee found to twi Moat affectivei
m nona of the patiaat atiowed faaoieulatioiia * Vigtm mt al.
(iitSI haira ihoifa timt Oaiianina (20 ag* 90 aaoonda prior to
auxamathoniiaiO can reduce the incidance of faaoieulatioiui
fxoK §2 to i2%» Ttm incidance were further reduced to oniy
2% when the aaiimdiMi was uaed in the done of 30 mg and
•dniniatarad 00 aaoonda prior to the mixaaathoniiM. Siitt
at ai (ifOil alao hare found the OaHanine to lo atypurior
mm smMmmaim* Thm immicul&tiom wmrm
tufmiSmrnM aftwr tha <0ali«nina pre*traatmat idiila th«

83

Th« po»t»oper«tiT« suxa-pai iw ar« »o»t troubl#*©®®
to to# |»#t4#»ta «tidl |>»rii«|^ ©ccwr da* to dwsay*#

hf «i« •w*«it»®thoB4a» <Collt«r, 197®) , Th/s pr«v«ii%ton
of «i*ch pmiwm Im tmmt di«alr®ifcl« i«»t only on hwoanitarian
growlid imt «l*o to tolfil 1*0 otliica of disci pliaa of too
aitooiitlio sioiogy «

'too prooant otody lion oiiown toot occunranco of
«uxa*poiiio «r« qoito <»iH»on, The of the pationt# in
too cfoottol gtotup of otwfly woro troubled duo to jprooonco of
poot-oporottTo nyolgia. Tho oovoro polno woro «l«o not
uiMOOMBon# oo ISX iwtionts hod ineopoeltiitiiif poliio.

Tkio oiaillor high itoidonco of poln oiao hoo boon
roportod to bo by C. Doiridoon il9S4) « €Q% br 1‘ootor
(19 SO) md §§% by Miloon* i.>iiBdoo il9S0) « £oon much 'highor
fjroguohcy of pedm hewe boon ohown by Biartloo ot *1 i^di)
and Mi^toofoJr (1959) toon too incidonco of aiyolgiio woro 75%
ond in too roopootio’o otndioo*

In fitot tlioi lucid me 0 oro quit# irarioblo and lowor
incMmco of nyalgio ouch m» 1*2% (Cronford# 1971)# 17%
(Croig# 1994) and 2i% (liofor# 19 $d) aloo haoo boon roportod*
Hoidia ot al (1975) haoo tooon this incidonco to too 52%
wliiio Mofoo ot al Ct9®7) tiavo oboonrod it to 57%*

Tim nido jrango of ocoturrotoo of too nyalgia ooomio

. 14 ^.

:?ill

of tho

■if icrmfm&w

mixmttioiiiuiii CBurtlo* Timatmi, Bill Cr«ig, WUi » tim
Awemtion of mhaXmtlQm i&mMmmt 19M) and Vm ponitioa
Mid tmtmxm of iMrfiorf • uisviotwlf# ttio afeMidojPilisatiaii of
•11 tho ifoirosidd vori«l9lo» cm not im nod* in • Mnglo
•3C|Miriwimtiil iBodol*

lljifor I fc4 Inti

that atfolgia tond to occur comnonlf «t nit* of n«e3ct
j«w« nliouldor#' •ntoriiir client wmXl, lowor <»ntnl leargiiin
and tile ttj^|i«r altdtondnal

B^tlnn* Timstall (19il)« White iSfil) Mid ixfaon
Omuiton (I9i3> h«ire rep»rted meK ihonidwrt inictoraln -

to h& the eoMMm niten at whioli
■ifelfie oeenyrn* Collier 11978) haee ««f tented that nmnclen
of iNiek of the neck and tlie loner l^raeie eege» owint to
liwee liigti n^iiwile mm ^0 mm mmm liatle for the lonaiae^intiMK

MMCJUl SMMflil IllifOliil 111

jii iiaiyttiiiialfe.i. Jhl i # «

S5

w«r« p3.«c«d in LithotPBiy position, which war itsslf t» «
esusatiirs factor to p^ddues hscksehs «

Qur O'bsorwstleos rsnrssisd that patioots of n%r«
than 20 piars Me bsios S0 r«srs *r« woch prom to dosoiop
th« nftifit • 'Itis pitisnts In oontxoi group lisirtt shoim ths
wfiiifia with ^hs iacids»c« of 7S% and 100^ ia th« ago

groups of 21*30, 11*40 wd 41*90 faars rasps otivalif,

Tha iaflusaea of aga orar tha occiyrriaca of stfaigia
.is ifall kasifa (@uSh, loth, ifili Sortlas# tunatall, liilK
Craif Cl904> has foiiM tht ineidanea of 13^ ia tha pitiaati
halcw 20 fsars m& l& Wm patiaats of 31 • 40 yaars*

Mo Myaltia oeourrad ia tha patLants of aora thta SO paars of
ago* Tha ooarall low inoiiliwca aight ha, hsoaosa

vajKonatlioniim was adwinistarad oaly is tha dosa of 2S «g*

Tha highar sascaptihilitf to hava maa-pains, in
tha patiants of mom lOum 20 yaara and halow IM> s«aars, also
has htan dasonhad by Bortlas, Tnnstall (Itii)* Tha ineidmoa
of ayalgia in «ich patiants wars obs«raad to rimain aroimd ii%»

Tha ohildran and patiants of niora than SO yoars of
ago haoo boon ihown to ba aiooh lass pcona to haoo nyalgia
(bash# both, lidl) • Tim childran ranain gaits aotioa, thns
tboir nasoalar Htnass prsoants fson #ia sasa^pains
Cliawiiaii, tendon# 19 Si) worawar thair iinsoio tissao oontaias
hlgbor psoportion of. alastie oollagan fibras alilob niniislso
tbo , fan tits thoadaiB iadnoad nasola dsnaga and so anbowant
afi«r*pai»a IHiiiid Soyaon, 1993}*

86

Th« An th« control group of the

present study i, h*d iiighex tendency to suffer with tin* suaca-
pain» to show the incidence ©f 72:^, while the IrKidence of
5S% wa# otoserwed aaiong the i&ale patients.

The higher ms cept Ability of the female patient*
ha* also been described by Leatherdale et al (JJ50)# **iding
(If 75) and hagee et al (IS®?). Bur tie a Tuns tall (19 61)
have olM©rved, idle myalgia to occur in 59 'A of the fesiale
patients* The male patient* were shown to be less prone
as they showed the Iceldeniee of myalgia to be 49'%* iewmm*
loudon (19 §6) have raported hi|^r incidence of myalgia to
be 30;^ in female patients when compared to that of 13i4 in
the Ml* patients* The rearon of higher tendenpy of the
female patients to develop myalgia is not known* perhaps
the honnonal infltuince be a causative factor.

Our observations idth the ©elf TMing were found
to be dieeatisfactojcy in the prevention of inyalgia#
patients in thie group euffered tdfh ivuca-pains and moreover
the severe pains were aamplained by* equivalent number of
patients <1$%) when compared with those occurred in patiimits
of control group*

Our observetions well correlated with these of
ifilson* Smndee (1900) who have also not succeeded in the
prevention of suaca«paine with the help of the Aslf Tsaning*
an fuite high incidemse of sy^algia was observed# which wee
iih in control group rod §7% in patients of 9mlt tmlm <3rocp*

« wcfitut thoal uiKi «

iR contr«»t to tii« m»t o£ tins studliaa*

Dar Mia U.mg&& iwm^ liair« aaaeiilva thm ii«lf to

ramda cffttatiTa ia artouciiig tto iiicia«iio« o£ Myalfia imm
S6j6 to 24^ with tot Jiholitiaa af th« ••wtra fwlat*

lR wimw 9t &m :&hBmx:wmtlm»t tXatifiiito toott af
othars# it mmmm that tht mtatturt of Ttoiog h«« no

•ffiotojr mgmimt ttm «ix«*p«iwi althongli it cm owsoostltii
ttttonuattt too ocouttaaco of tho £ft«eiciiiatioa«* fhiit# it
•ito hRComt mviamt that to* imsidono* ima int*n«it^ •£
thtt faiseiotAXatioii* ha* no affaot ovar th« ooctmrx’ina* of
to* •ujca^n^alfia*

pern mmt attof whmtm toat to* ntaanr* of
procoraritatiem ia itnto laor* jonvpoaafai than tha toif

Kith

&courr«nc« #f th« auaca-ffif algia • Dwldaon il.9S4) hsm xL»m&
thin 4jmg in t}i« d0«« of 40 mq to show tho succ««aful
roduction In tlM IncMfiEiea of i^nlgiiL fioii i€ to 40%*
vthito (3Sii> li*4 •ignificatitly rofliao*^ tiio inoMooeo of
miraXgio imm SO to 20^ mmn #ieii tho Imtmx 4o»m (S »g«)
of OaiiMRiKMi woo a^Miniatoroi* -

Baonotta liaira alao aooeaadad

aith thm Gmllmlmm ilO mg*) * in tha pK«tmtl&n of m^falgia
to aaitioa ttia ineidaoea of anaiH'paifia Mmm S@ to 33^«

iacManca waa furthaa lowairaNa to 30% afeMn tlia 20 HQ of

aaUanioa waa lauiad

farraa# MiX'aldfinr and Craig Cif iS) haoa |%sooad tlM
affi«a«ir of tBa Oaiiaaina pra^traatiwiit* Tim iaoidaiMa of
Maroifio oova iowarad fmm 41% to 30% onaii tlia pracmraxi satioii
aaa ftrimraiad 2 adaiitaa i^ior to tlia auaaMtlioiiiiiii* Maaaf

Th« with th« paihCisiraEiiiin« ha'r€ r«Miin#4

«•£« also r«diic«id fron $S% to 20%* Ifodvrata «ffieaCf of
th« drug hm» mlm n^owii hf i»un« «t al (If 79 ) md wig* Bail
( 2 . 979 ) » Ciui«y« Siitt and Qmxlmn (Ifil) haira £auBd it ts» Im
•upariojT ttmn Qailamih** d-tetoouxajrina m<A iBMitacujriii* in
regard to pro^rida adaguata raiaxatioii aiongwith affaatiaa
pravantioo of ttm amiea-paina •

Bannatta* lOiaiii (IfSl^ haaa got aueoaaa# with tha
paacuroniwB (1 ng*) pra*traatiRiiit» in tha aignifioant
raduotlon of auxa-agfaifia front $3% to 28%* Farraa at al
(2983) hava uaad tha paneuzoniwi (1 ng*) aithar at 1 or 2
minntaa prior to aox«Mithonii« and tha iiweidahca of nsfaifia
ware radoead fron 41% to 2%% md 26'^ raapaotiaalF*

tha aaliamina (20 ng) pra-traatmmt rm%lm auparior# ^haa
cx>tRpdr®d to tha Paif Tareing# in tha praTantion of tha
wyaigia*

3ullivan« wiliian and Calaay (1988) haaa fomd
panetizoniiiM to ha aaparior aa aunceh loaar inoidanoa of
myalgia (iMdian aeora 8*S) wara found in paaouronitai fzoup

eo

MyparkalMBla i

^ai til* in tl«« oontxDi oxoup of oiar uttiOy

liad d«£init« ri«« in tii«ir man piasMa potaaslwi csoneantratioB
fxum 3* @2 m iml/h to 4*10 m wot/l> to iihow thi man ri#« V
of 0.2S m ml/h at 3 miituta intarval. TImi potaanlu* Xaval
r««aimd hlghar irraa wpte iO vihm tii# man il** of

0«i2 m ffloi/l* «#aa oi»arir«d* Th» maiatm riaa# in pXama
potaaainffl concantration, of 0*3S and 0*16 » ml A oecurtad
at 3 ifdnata* and 10 minataa liitarv:al raapaetimiy*

Sliti Mild and tranaiant liaa in tn« i^tasaiiaiB
oonoantratlan# in rasponaa to tha snaiiiMitlioniaiR* lias iMan
abown ty iM>npp at aX , #aton at aX it9M) , L4at <1947} ,

stjtiltair Morroif (1969}, laXif i^indaa (19741, Magaa at al (19 94},
liaqnib at al (1997} and kiaaar at aX (1997) * Matta at aX(i969}
ham Bhom m mm tiaa in plaana potasadLtnR nonnantrationr of
0*4 HI laoXA# 0*3 K moXA ai^ (}*S m ml/t* at tiMt raajpaotiva
tiiaa intariraX of 3, S and 10 laLnntaa* Hiilar at al (1972}
hava maanrad tha potaai^nm Xaaala to idiow tha tmm riaa of
0*3 and 0*1 ai nolA at 9 and 10 winotaa iatanfala raapaetimly*
KonebigaJti at al (19?9> tmm daaoillMd tba pot *441 on laml
to iliQw tha man Aaa of 0*43 m mX/h at 2 nlmitaa, 0*2 m mX/h
at 3 Mifiiitaa, 0*11 m molA at S nlnutaa and 0*06 m ml/h
at 15 ffiiamtaa*

Millar at al <1972), 9ali# JOmsdaa (3974} « Sliatta
at al Cxtiil liatra ahom loraiataacra of b3par]ialawia
tt adnidEaa* Mowamr# Maaaa at al (1969) « imatctiigNari at al

31

htt¥« shown thst sue A xmMs>Q»»m la* sustsiiMid for
«ir«n upto 3.5 minutes*

Tim pr«s«at stud^ shows that both th« mstesures#

pre-induction vsitics for st least upto the 10 minutes* after
the suxamethohium mteihistratioii*

The efflcacf of Tming was obaerrei# in irosent

study# liien potassiim eoneentratiofi siiowad a f«i«Ki fall of
0*li m mol/ls and 0*13 m mol/L at 3 in&d l§ rninut as Intsanral

respaoti'raly* The .maaimtie fail of 0*34 n maX/h and 0*18
m m&l/h wara found at ^a raspactiaa time intarval*

i:%M Saif Twninf also has baan aaaluatad by thatta#
Ituiay wad Daiiipaiida (If il) to eonoluda that this isaasura is
quits sffaotira in tha pra^en tion of tha rise in potassiisi
oonoantration* Tha maan fall of 0*3 m mol/l* was obaanrsd
at tha intarral of 3 wtinutas* whila tlw mesa fall of 0*3
M wal/h par sis tad from S to 10 isinutas*

ftis sffisaoy of salt Tminq has also bsan sAiotin
by hsfas# osllaqliar C 19841* Tha wmm fall in tbs plaswi
potSiSidtaai oonosotrsdions# iras smssurad to bs of 8*33 w insVli,

B2

iJulliiran ®t al (1983}, howiv«r, h«T« ola®«nriid no
ehangas in tht mem potasaitai conciORit ration fxon valia*
of 4 ,00 m ml/h %8jian tli« Masnrc of B«lf Taming w«* •Bplojfmd#

Th« obsarirations in prasaat atudy MuggmutM ttuit
th«i praenrariaation aitlMir with th« aaXiwina or %(ith tli«
pancujDoninm nan attannsta tlm ao'jca-lif’parkalani* upto tl^«
significant mMtmnt*

Ths patisnts in Qsiiamins group of the jarasioit
8tud;ir wmxm ironing the aM«n potasstum comsntration to hs’vs
a falX of 3«20 m »oX/i» at 3 mint^ss intsrvaX and 0*i4 n noX/l*
at 10 minutas intarval* Ths aaixintan fall of 0*33 m m&X/h
and 0 .li m mol/l* oeeurrad at tha ratpactiira intaraal of 3
m<& W niiiutas*

rnM-rnm . 11^ j|pa> w *" %«• Ife li ®.,li , mm mm Jfcl# IM'liwI Wm

aguaXXy affaetiva in this ragard* patiants in this froii.p

shoaad tha aMi«i potassiisn csonoantratioiis to hava a fail of
0*22 and 0*17 m m&l/i* at tha intaraaX of 3 and 10 aiiiiiitaa
raspactiaaXp* Tha iMMClmm fall of 0«33 and 0*1JO m mol/l*
wara shown tha patiants at thasa rai^otiaa timt intarwaXs*

Tha afficacjf of tha OaXiaaina# in wAnimlmim tha
susca»h|i^rlia lamia* has hmin showti by KXupp at aX iX9i4) #
fttriltar# Morrow (196#, Sirtoh (1970), Cim^iNixmaii (1970) and
dronart Thapa (1973) « f arras at ai (1983) hawa sucoaadad*
with Vm OaXXamina (20 mg 1 niikiita prior to tha sastainatlioiiitid ,
ia radaoiiiD IPs potassitw conoantration to hhaw a mm faXX 9M

©•2S m BJOl/JU at tha intanral of 4 and of 0.12

m wol/h at tl» intarval of 10 Mdimtaa*

fliMi afficacy of idia jpancui^ooitw naa toun ahcwo
toy Jwsnchigairi at a I (197S) who otoaarwad a Maxinuw fill of
0.31 m mol/L in tha potaaMimi oancantration aftar this
pr«-traat»iait. a mm fall of 0.21# 9»li, '©.If and 0*11
mol/h waa obaatwad to Im px-aaant at tha raapactltra
intairaal of 2# S# 10 and IS Mlniitaa* f arras at al (1903)
hmvm raportad that tha iwneiiioniiin pra-traatnant Cl mg
2 miniatas prior to tha suxwmthcaiiim) cxtnld raduca tha
maam potassitm concmratratlon to iTiow a mm fall of 0*IS
and 0*li m mal/h at tha intarvals of 4 and l@ sdnntas
raspaetiaaly* Coincidantally# tha affioaey of this pra«-
traatoant : was lowarad if tha panctoronltmi was adainistarad
only I niamta prior to th« siaaiaaatlioiiiiiii* St&lliran at .al.
(19161 hava suooaadad to show a maan fall of 0*2 m mol/2*
in tha potasslwm conoantration aftar pra*traatmmnt aithar
with tha SaHoaina or with tha pimouromitwi*

Koida# Waod (1972)# iasu at al (1973) and itoaltingo
Patarion » howawar* hara fownd tha praourari sation to

ramain inaffacMwa in tha pravantion of tha swxa*hyparlMilaKia

flit oaaorali raaiaw of tho prasant ataody swgfast
tint thw laif Tamdng earn affiolantly praaaiit tha arnica*
iaseloniation and tha stcaa«hyp«t]cal'a»ia * Howawar# it tias
ho hifnifloafit of fact orar tha oooiirrmiMa of tha aayaliia.
Inridhi (SfTt) has suggastad that aithar noiiro^imisiciiar

B4

.-.iiiiiii
■ ii*l»

accoswtod ati on or cS«#«nai tatlon of B»tor and occur with tli«
preliffiinary do«® of tti« suxawtthoniuin, 1?hu»» tfi# iwignltiiiiii
of tti® d«polaria*tioii «ft«.r th« «ub»«ou«iit full don® of tho

TOxamethoniuiii is aiinlmissa loading to radnictlon in th«
occurranca of ttiws fasclculation and tiia hyparJtalamia#

Th« pracurari station s««irs to bs laor*
than Self Ta»ing in ragards to r«dw:« tha nyalgia in th«
algalficmt atannar* Tha pancumnimi Mr® affactiirtlsf
pravantad tha nyalgia th«» tha faaeieulations to mduca
tha inoidanca of fxom 65% to 2S%» imt tha fasei*

culatlon wara still visibla in 90% pa ti ant a* The aallwiiMi
had nora pronounead affact in regards to peasant tha fasai*
eolations# as tha:r romaiiiad visihla onljf in 20% casas*
Mowavar# tha Galiamina su)d tha i*anouxoniUBi ahowad almost
aqual affioaei' .in attanuation of tha hf par lES^lmic rasponsa
to SIOCSMlthOllilWI*

**«•**#

m

S5

Thm m&lyBiM oi tii« ob««rirati qua Ib th« prassnt
•tu<Sj show* that th9 Qeeturswmm of tho po»t mxmmthtmiim
£«»eiouX»tion» and pout -apt rativw mymlgim it qultm higli
and th« suxamethonium oartainXy ifulucts a dstinits
hyptjtkaismia # in significant mimin«r« to pair sis t upto
10 minutas#

itia fatcicuiations occur zad inevitably as to
raiRain visibla in each @f tha patient in canti»l group*

The tuccattfui suppression of thasa fasciculations can Km
ototainad aithar with i^alf Timing of suxamethonium or uith
pracurarisation hy using small dosas of <3allamina as irall
as tha PaneuroniiUR* all thasa laeasuras are significantly
affactiva O.dOl) in the inhibition of tha incidmaca

and intansity of tha fasciculations* Howavarii tha Oallamina
pra-traatsMSEit is imost suparior# in this ragarda# Ihllotfad
by tha swasiira of aalf Taming and than tha fancuroniiim

Tha overall ineidaaca of post-oparativa mpca-pains
also aaa to ramaie diatraasingly high in tha noo pra-traatad
patiiiita* CioiMidiantally# tha patiants within tha ranga of
21 « il faairs of aga and partioularly the faHslas ara highly
auaaaptilila to auffar with such after -pains* howavarf the

i&mrvl&smmnt ot th«a« pain* ha* no raiatlon* idth th*
iBci4«Bc« md 4i»t*ii«ity @f th* p©»t »nJcaw»®thoiaiiijR
fdacicuXations* ' Tl»t Macui:* of di«Xf Taming remain*
ineffectif* in the «tt*ii»ation of thss* aftar-jpain* and
incidmac* n** to ramain iarg«ly iin*lt#r«d (F "7 0*3) •

Th« pre-treatmimit with th« pancuroniuiR ha* th* higiieat
efficacy to mitigata th* incidmea and int«naity of tho
myalgia CjP Qm02) » 'Mkmmrmr, 'tho GtdlimiMo
i* also adagnataly affactiira in aignifieaiit inhiMtion of
th# •mata-niyalgi* £. 0*3S} •

Tlw |io*t«*«iieimi#thonitw hyparlealamia is also an
inavitahla plwnoiMinoii* Tha plaaiaa potasaivii csonointration
tand* to ri*# aignifioantly mom than fr*<-iBidnetian laval
for atlaaat apto Idm 10 minatas Ci* 4. • '!%i8 respons*

to saxamathoniam cm, larg#ly» hs inhibitad by tha Miasara
of tha 6alf Taming as nail aa tha pracararl nation
(Fatioasoiiiam and Qallamina) to loaar th* potaaalia*
coMaAtration aignifioantly laaa than pra«*indaation iaval

L. o*ooi> •

X

X* l«Xi» l«li# wid i3*w* iX074> i <aowt:am of

46, 8Q3. '

i^^» i

I* ®«ii, Dui%d#«, «ru3i Assaf, AmAm'im 4III7S) •

i» »l&mm potasaiius# aodliuii And
: . eliioridA c»iii8«0t3tA%ioo indiacAd by AuxiHMitilealinn*

47, Xfl, . :

3« BarAbA auXa# (X977) t Aalf Tailing of suecinyXcfkoXliiA
inducAd fAaHeicttXAtions*. ACMAAthASioXogy# 46, 29 3 «

4* lAAU* AgAJnfAl# K»C* And niAtAAfAr# NsO* (X973) I

AtucAiBttl»oiiii» indue Ad hyiMurkAlAiiiA in ternA Add trAuiRA<
Xnd, d« AnaAAtb., 2X« IS9*

S« BAXiB« JCArXAAll# C«I« (1966) l C;A]rdiAC AWAAt iB

tiMi Irnsmid fatlAiit AwseinyidioliiMi AdminiiN*

trAtiOA* ABAAAtllAAiology# 37# $16«

i« IhMABAttA# f«S« m& iMLiX# 1C«X» (39ii) t AAdliaetitiNBi »f

jpj ^l|%. jptyili WdilUll t>&Wt

4b)P*lAyCillill0 AfiMItA* S<id«A«# 93» SIX*
f» ftiiAlif A*4«t MitelMiXX# AMi fXif^dojrd# ci*A» ISiif) •

iji mim mm ii ^ii.ifc.iiyiil., - mm tm mmmmi liiiirt Aiifei. I., iMi

.i»il4ntlJi0 triMMA# dAtiA# il9^ #99*

XI

;

BUtt« Caxlson, (i*h„ lioiUiig* g.l*. «t ml t .j

A oompmmtlrm «v«liMitioii ©# pr«-tr*ati»ii‘fe with uois-

: ■ ■ ■ ■ . :

<3«po3ji.risif$g ©awro-museyiar bXoclwira prior to th«
a<(lRiiinti«tration of nuecinylcholint • mmmmUim miologf $

\

5S, 6i9.

9« ioiin>«# i3»Q»f CoiXior# CtMmQoJ mmtt c«f* (i9SX)i i
' >iyc«siyyX«holiMi# a muacXa raXajtant of short actioo* |

hmmtt ■ U 1225 * I

X0« BroiSaky* a*»*# ixoek*iitii«« J2f 79> i hoaa £i«Xf TawLhfi
wil* ,««oiayJ^ irairaKita po«t*oparatiw« ayalsla*

aaaoatlMiMoXofyf SO

IS. »ro 4 »l^* J»Mm, Bmek»utm, J.o. m& smmlm* *.x* iiitS) •

Pmaiimmmlvm pra-traataant aad poat«ai3WielayXtfiolii»
■tyaXfia* aasaathasioXogy# Sl« 2Sf«

xa« Bryson* T»ii«L* md -OmmtoB* T*a*o. (itS2) t Mtisela pains
foiisifiiiO mm nsa-of syx«iiotho*iHi» in oaasaraan saetloiis.
Bwl «i4*f J4# 47S«

g $0 Bnr«t«s» B* CI94I) I NyseXa pains aftar mmmmmittmaitm
ani Binis^ianiiisi* i*J*a.* 33* 147*

14* BiTtlas* B« and ^^unstali* li*B« Cifil) i MmMmmmmivrn
siiiaiffMs and imsttia pains* B.J.A., 33# 24.

!*•' IMWii* aiMl Bath# »*.■ itfit) • Unsala pains aft«r
iMiMontl^^ aWai'iriia in ohiidisn* »*«2#k** 3J# iSi*

in

16 • Ciitlrfo Mtid, y»lf (19 61) i

iadtie«4 mmelm f a»cicul«tloi>s p&ima

in jpatlcnts anaasthatlsad with Halot}mfi«*

30 « 1 1 1S7 • .

n» Chujrchill-MwMaon# ff*C« CUM) i miJcwffiithanivuii (•uceixi]^^-
dtioliiHi) chloirM« *ii<3 miMiciw pains* «* l« H*

IS* Collisr^ c* iig7@> t •>ii]c«iMitlieriliifii pains sndl •arlf'
iilsiitxDlft* @n«nfss* ^^asstlMisia# 33# 4S4*

19* Conies# M*# ifo c«lli»d# »*M* and Sinclair# a«H« ili63l i
Mnscls pains aftsx l<4Hi* suxaMittionlw c^lorlSs# B*J*a,«»

35# lat.

30* CiK»iwxi»iyp# liiieelnfloliolins iaSnosS hypas**

lialsiila in nenro^muicular Sissasss* JM&k 0 313# 1S$7«

31# Csopsrssn# l**M*# stxobsl# S»K» anS Ksnnsl# c*il* <19701 t
Hasslvs hfpsxlcalasiia aftsir sasinis tract; ion of snoelnirl-
flUslias* Anssstiissiology# 32# til*

22* Q»w 9 ill# B»« Nostsll* and lataypinGi# HJH* (3974) i

iteesplaalitis auwl hypaxiialmim rssponss to sussinsrliiiolliis*
Aasssttisslslsgjrv 40# 409«

33* Crsif# lt»44} t ihs protsotivs sffiMt #i 7|iici|is»t«ss

' mmmimr pain and atifCiMtss which follows tlm tUMi
of ' aaniMMsiliM^ si« iit*

14# (Srawiord#. 0*S* (19711 • mmmrniimmim mamSm- fihina md
PropMMtp# ]|«d,fiNNf '4I«

t$» Cuii«n« (1971) I Th« ®ff«cta of pc« -tr®«tiB®at

with oois»tf*pol«ri*iijg hiuksI® rolaxwats i» tli* mvam-
pwicnilar Mocklttg action of iiaccinyldaolia##
Ai«i«»th«»iology, 35, 572.

26. Oomaoal, A,M,, nmigmr, F,c. a«d 'mlfmnt B. (197S) *
•Pr«euriuri»atiai3* uaing tfancuxoiJiua. Ana®*. & Analg,

CoXX*' f 54, 1, 7l».

27* Durant# and *^t*# M*k#d* (1982) s it»wjciii®thoniwm*

l.D*A., S4# 195.

2i* Dutt*# a.# Crockor# D*S. and Alp«jr# H.H. (1977) i MuacXt
jpain following adn ini at rati on of auxamthoniw to pragaant
and non^pragnwit l«tl«nts undorgoing laparoacDs^c tultal
ligation* Br* <7* Anaaato*# 49, 425*

29* farraa, C*«J», Mirakhtir, b*k*, Craig, «t al (1991) ■

Fra-traatmant with iNHmxoniuii aa a prophylactic againat
l«#t*4toiiMtooniiiM nuacla paimi* i*i7*A*, is, 73$.

10 • foatar, (2990) i Miaacla paina that follow

nAalAiatratioai of oipfaMithoiiiiaa* 1, 14 «

31* Vosoihl# 0*B«, Hanford, I#<44*D* wid Harria, A* (1977) t
i^aitothiHiiwi foina and alootsoiiyogriph rocordiiig in
^ ohilditii* Br* «7« anaotiii*, 49, lOS?*

12, ftoii'liitillMi, 0«O* and DrMnond, il.C* i Kfpirkaiaiiiia

aft«t " MKOiiif laliolino adniniatratJMi in a patiant with
oloaad hand $MSwe^ without Faxaala* anaoathaaiology, 47, 144

^ '/f' '•«<#.

3J. Wmwd* r.G. and rwMb, ilfta) • 7li« «••« for

•^^tioool . ottcciiiylchoJ^^ «f««r A^^hmwcmxlm *
AMootteoiole^y^ 3i, x@S*

34* Glilaiii* Oor# #%•&• and iMmgoo# M# Cl8»84) i

#««cElaylchiolliMi Soif Timijig - offact on mw»cl(i faooi-
ettlotioiui «»d poins* i*a*A** 32« 2« 270*

35* Grooort# g*a*, Tltaya# M*A* (]p7S) • Foftio-ophyaioloff of
HyparkoloMio indue ad 1^ muBOinyXehoiine* ^ 4 Mio«li«iaol 09 yt
43* 1, ii.

34* OuFlo* 4*M«* omp« 0 t« li»4* (1971) t iOat auxonatlioiiitM
paiiyi and Vitwin c* ^naorltiaaitt* 24# 434* '

37* Hikfiurtar# f* (ifm) • Fsotnepirotivo iMocio a«d«A**

ti, 2®f* '.

3d* Hiiaio# ic*d*# CMttorji# d* and Kaekar# a»li« (1973) t
intjravanoua iiptoraina itox pro rant mn of ptaaolo pmM,m
afiMHE' I I **ir t Anaaa* lie Anal*# S2# 949*

39* liidiiMMii# A*« dap# M* «tid Xaekar# s»li* (1977) i Xnfluonoa of
prior adoinioluratiofi of di^OalPNBiararifio or of Ittwr on
aojiiiPOlliHMitap iifhiood tijpiTka laai 1 n in piiianto pi^ or

oiOIppp lupoupoii 3i# 143*

4t* ^ fipiMRiPi# , §«*(;«# itiNOMi# F*ll* (1979) I Okjootivo iPiMiraMiwit ,
of ' ipti«|iiy|«lko3iiio Xm&m*& f aooieulatlofto and «)» aiCfoot
of pro*tiM^tM«i% witk pinoujo&iiiia and daiiaoilao*
inaoodldaoioloiiy# tl« iS9«

ttlISliiiil

41* 0**., ^luwaJLitt. Bmhm md Slisgh# P. C1976) i

ll#«t*olyt« climg«s ia th« telocwS aft«r aia^JUi ab«« ®f
•axiMMtiioaiiMi* 2*J«4..« 1$76« 41*

42* !•* Hagaina, €*, MaAia, (19 Si) i iatabatioa

ooBdltion and aartim potanalaiB lavaX altar aaiia auacla :
ralajcweita* Xm 7«^., 3?« 4# Xi2«.

43* Kaadliag* a*J., iwakar, a*P# and Badow# 4*. (i»7a) i
dataiafXcliollaa indiicaa tif'parlcalai&ia. 34# 2« 132*

44# Xhaa# ‘f.t.* and lOiaa# B#lt» iX9d3) t ciMagaa la aar«»
patacaiiM faXlowlag atacoinfXciioXiaa in patlaata ititii
iafactioa* <^aaa# aaaXg## 43# 327*

49# KitaMiura# 4#« Ifatliifa# X## Tadiiiro# c# md Magialti# 7#

(1993) I 4iit«iar3aliaXiaa eaaaaa: faaaieaXatiaas lay pra*
JaaetlaaaX aaid&aaiam# aanwaliliaaioXagy'# Si# 3# i% 223*

44# JCoiMia# M# and Waiid# B*s# (3972} • 4Nmim fCMtaaiiiiii utiaiifiHi
aftair anaaii^IaliaXljia ia pitiaata wim »&wtm maX faiXwt#
4tka«91dl««i939Snr* 34# 2# 342#

47# aEiin«)iif«ri» li«l«* «i9 7ar# (3973) I XaiX«»a«a af

pwmiKafiiiHi #9 pataaaXwi afftm pfodiaoad if «acNiiafl«li»3i»a#

49# c«# latliff* a*# rXatMiitr# 4«9* at a3 ClttD t

mtmwB I^tav aitaalJiftoiioXiaa aiaiiiiitffattott
la 'istltii^a ai^ aanta Hi9«lv9 iMiala tjraiaa*
4|ia99l3l*lll.#la9f# 34# 244#

49* Kwmmt, F», II. wad ^Uasti^ ii«li. i mt« C«

and •«jnuuBi jpotavaliaR iift«r suxwwthoniiin. ^vrnam

of Ai}««s« wid ^cm, a# 1S2.

90« IrtidtiM) jrdaa* « Rmhmhmt and H* h'iliiaiii. !!•<&«

(3JS$} I inclBmmm of aiiaoi* paio «ft«r aHoirt aetiim
■Mtelo iraiaxMat* . fOI*

$l» (If 67) c potasaiuM oliaiigaa Bmxlmg

WMioaldatMa* SS« iff*

,S2» lmK»xmmm 0 Uirbaeii* m.f* (if60> t iaoldanc* and

pravantion of aumelji {win* folliawiiig adniniatjrctlon of
waximitlioaioM* ^ooatieMiatioIOiy# 21# Sfl*

S3. HOfOOf &mAmt follllUIOII#; it.J.ft. (If 67) • XffOOt Of OtVOlMfet
•MHifOiiioo «« wawaiattlWMiiiMi iadiaeod f aocrloitiatioo and
nOfalfia. SoJ^A*# 1^# Sf6*'

§4* Mofoo# &mA» and OaOlagliair# s.is. (1964) i "folf fandlnf*
of aayaanof laonf mR and aanrian jpo%aaid(iflO oo noon fira4£ Ion#

».d#A«« s«« 977#

iS* Maooof# «»A#« QIaiMl»ir«iol(.« c#iii# and Onat# v.a# (1963) i

•oaMMtlioiiiiiai A mm Imh at pro*ttoataont# 6.aA..« Si# 726 «

id# A#o* and war# (if7D t liitoao«tl*» Iwtifoatt

^ " ' '' < - kmm. lIMjbMITiyLViliJItt ### #€

s,, tw ipp ippi'P ow ngp twwoiiP" i|ppw^ mme ‘PfOpifP w’ tFwra^F'

and. itollMyMi in naiift nnoontiioaioioif# 37# Sit#

mil

57* Millar, S.X3. and Way, W.I.. (1971) i iuhiteition of

•tici0ii;tyleiio3i.xui indue «d ineraaaad liitfo*iira«tric {srasaitt*
toy n0n<H5ii»olarialng Kuaela ralaxanta and hl&oottkm*
Aaaaatotoaiaiology* 34 • 2, ISS*

$0* Millar* l%*l3i** Way* w«l*«* Maailtaa* w«Ji.« and JUaysar* A*B*
<1972) t ^i^einyldfiolina inducad hy|Mir)aKlaKia in patianta
witli ranal failiara* iuaaaatliaalology* 16* 3« 138*

59* Morria* £»*D«i« and &um* C.ii. (iff?) i SwKMMitlioniiaii

aMlorida adainiatoration and paat>Kiiaiaatiaa amaela pain

»*lt*J

farag* H» and lia«)Mif)MK»la# d«n*a* <19i7) •

60. »agiii)i* M

:|ip| I
^ J

11^1

aXX^Ctii #£ pr#<<^ 114 4i€Nil^l CiMiSf'JlIIIIII #li

amciMathoiilum induoad nyalgia# B*d«a^** 59* idi* :

61* liaMBWB# P*T*?* and howSmtg i?*M* C1966) • Miaaela padn

ioll49nrifif adniniatration of aiMcaiNttlioiiiifla <• idia aatiologiaal
sola of anJMiilajr iiitonaas* a*J»i** 38* S33«

«S« BaaMKook# 0*&* and Miaraa# a*F*if* (I960) i Canpaaiaaa
of peato^apasratiaa pain «nd atiffnaaa aftaa t)ia aaa of
a«uiaaMrt)ii^ and aaxatMooinn eoapenada* B*at*d»* I« 303 •

61* 'liidiMa* (101^) • tiia affaata of noMila aolananka

' m mmmUrn if# t iiHii M . Wl « ^ n# ii#t|# rt # ¥# 4SS«

j 7^P^''nllPIPIPflpiPIP6fP' ( <' pipsiPolWiOWisSP ’'ffoapsw TipaiiPi ^ T»pifiip(p,'-«pisr 'iPP’iiipK-'Bifa': app'iipp'i|pp. -11^ ■ ■'jpr. ■• ' :, ^. w ■

6i« fttiiHio idMLilOi' t* (I9i7) « ^acaaatlMMniiiai ami poat<«o|Miri*iva
mtaaln palwi* B*ii*3*« i* 7ii»

XX.

»mm k&Qs K. and a*Ja, M» Ufti) » 3mmm

potaaaiim Amagmm foliowing iidniiiistjratIjQn of
MtDonliaii ill tr«i»«ti»«d pitiont*. ISIS, zm.

fid* Both# f* and Wwtiiricii t iht ciiojteal i»port«nc«

#£ hyptrkAloBiia folianlog auieamithoBluii adeiiiiiot ration*
SWvi*, 41, 111.

m

73# TolMiy, «.£• (197t> i JPamplegia, suecinyleholint mil
cardiac airrast* Aaaaathaaloiofy* 32« 3S9«

?4* Tcinla# il.i).* aoyc«, T«H. and Niteliall# 6.&« • : :V

^wcinflchollm danger in th« feiutXMitl patiant*
Aftaaathaalology# 3i« 467«

?$• ffiHMiato# T* and Mraksinaiit M« (1946) t IncraaiMi

craatiiia Icinaaa actiirity in aarma • a aign of lattaetmlar
injttury eaiaiad 1:^ intamittantiy adainiatarad anxa-
Bol^onioii during MalotliaiMi t^aatliaaia* 38» %tB*

7i« Vanaa# Qiattarji# a* and Matliiff# M* 11978) t

Masapan and aueeinyidioiina iaduead naacia fraina*
juaaaath * it Anaigaaia* . $7« 29S.

77* Va«r»a« (if7f) i "laif Xapaing* of aoeeinylefioliaa

faacieuiatioiui and intra^-ixsular praaaura* AnaaatlMiaioiogy#
45« », a4S«

78* Virtiia# <197$! i CtaNopariaoii of dailaaiiiia

lKiaN»oiiraziiM of facta on fajMSiefuIatioiia of aiiciciaylckojyyM »

QmM* »mmmt S4« i« 8t«

79* and Maplaaon# lifts) t BmtmemWtmiwm

fm i. ii i i * lljfjpotiiooiji and olaaorrationa* AaaaarlteajUi* Si# Iff*

§8*''' M*P*# MaiatarlMap# P*7* and CoopanaMn# li«)l«

l l ii pp l § dMaiaa IJI piaaiia potaaaivai oooo oi, %ra t l oti aj f tiifT
dopoiaydlatiif itSooliara in viaaafliatiaod aon* 8«a*a#«ii, 1848*

MX

dim Whitt* D.C. Cl9i2} I OlBstnrstioiit &» tht prtT«atio>ii of
mmiSlM ptin «ft«r suxwittlioaiwii* B*J«M** 34# I32»

wig# i3« tai Bali# i«ii* (id7S» s Halation of i^rwsmrairi*
SfttloR «« 2 xamtho&ii» to pjco¥M« oajit of intiil»iition
and to pre¥«nt poat*swiiaMthofiii» Miaiclii pmlm»

Can* MmmW%m,S 0 Cm «?*# 2i« 14. :

93* wiljwtit# ' JD«B» and x>i»d««# (ifiHd> t Failtxt of dividod

iotaa of steoini'l^olino to rtduoo ttio ineidancio of
1^ pains* ^^oaaa'thiaiolofj* S2# 373«